|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 0143-9681-01
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.34 |
| 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 |
$1.40
|
| 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 Beech St/Commercial/PHCS |
$2.34
|
|
|
GLYCOPYRROLATE 0.2 MG/ML MED NEB SOLUTION [192223]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 0517-4601-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.36
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.70
|
|
|
GLYCOPYRROLATE 0.2 MG/ML MED NEB SOLUTION [192223]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 0517-4601-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$11.70
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.39 |
| 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 |
$0.23
|
| 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 Beech St/Commercial/PHCS |
$0.39
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
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 |
$0.06
|
| 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.12 |
| 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 |
$0.07
|
| 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 Beech St/Commercial/PHCS |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.39
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.70 |
| 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 |
$0.42
|
| 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 Beech St/Commercial/PHCS |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.34
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.34
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.70 |
| 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 |
$0.42
|
| 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 Beech St/Commercial/PHCS |
$0.70
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.97
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$1.97 |
| 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 |
$1.18
|
| 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 Beech St/Commercial/PHCS |
$1.97
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.87 |
| Max. Negotiated Rate |
$449.82 |
| 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 |
$269.89
|
| 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 Beech St/Commercial/PHCS |
$449.82
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
IP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.87 |
| Max. Negotiated Rate |
$479.81 |
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$479.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$359.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$329.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$449.82
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$528.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$768.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$576.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$528.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$720.00
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$528.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$576.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$576.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$576.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$576.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$528.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$720.00
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
IP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,593.61 |
| Max. Negotiated Rate |
$2,317.98 |
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,317.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,738.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,593.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,173.10
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
OP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,593.61 |
| Max. Negotiated Rate |
$2,173.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,738.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,738.48
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,738.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,738.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,593.61
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2,173.10
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
IP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$568.39 |
| Max. Negotiated Rate |
$826.74 |
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$826.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$620.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$568.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$775.07
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
OP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$568.39 |
| Max. Negotiated Rate |
$775.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$620.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$620.06
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$620.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$620.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$568.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$775.07
|
|
