|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 70860-781-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.87
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$2.34
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
IP
|
$13.80
|
|
|
Service Code
|
NDC 0517-4602-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.59
|
| Rate for Payer: Multiplan Commercial |
$10.35
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
IP
|
$10.56
|
|
|
Service Code
|
NDC 0517-4605-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.81
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 0781-3825-71
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 0143-9682-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.87
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$2.34
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 0781-3825-96
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 0904-6709-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 0904-6709-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$1.77
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 23155-607-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$1.77
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 23155-607-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.58
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.87 |
| Max. Negotiated Rate |
$479.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$359.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$359.86
|
| Rate for Payer: Cash Price |
$329.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$479.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$359.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$359.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$329.87
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
|
