|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 45802-046-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cigna of CA HMO |
$2.21
|
| Rate for Payer: Cigna of CA PPO |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Senior |
$1.26
|
| Rate for Payer: Galaxy Health WC |
$2.69
|
| Rate for Payer: Global Benefits Group Commercial |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.53
|
| Rate for Payer: Networks By Design Commercial |
$2.05
|
| Rate for Payer: Prime Health Services Commercial |
$2.69
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
OP
|
$8.57
|
|
|
Service Code
|
NDC 24208-580-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.26
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: Cigna of CA HMO |
$6.00
|
| Rate for Payer: Cigna of CA PPO |
$6.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: EPIC Health Plan Senior |
$3.43
|
| Rate for Payer: Galaxy Health WC |
$7.28
|
| Rate for Payer: Global Benefits Group Commercial |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
| Rate for Payer: Networks By Design Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$7.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Other HMO |
$4.29
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
IP
|
$8.57
|
|
|
Service Code
|
NDC 24208-580-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California Commercial |
$6.32
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$4.71
|
| Rate for Payer: Cigna of CA HMO |
$6.00
|
| Rate for Payer: Cigna of CA PPO |
$6.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: EPIC Health Plan Senior |
$3.43
|
| Rate for Payer: Galaxy Health WC |
$7.28
|
| Rate for Payer: Global Benefits Group Commercial |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
| Rate for Payer: Networks By Design Commercial |
$5.57
|
| Rate for Payer: Prime Health Services Commercial |
$7.28
|
|
|
GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [116094]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
|
|
GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [116094]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$13.17 |
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$13.17 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cigna of CA HMO |
$1.52
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: EPIC Health Plan Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.84
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$1.00
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: Prime Health Services Commercial |
$1.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.52
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.87
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Galaxy Health WC |
$1.84
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Global Benefits Group Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
| Rate for Payer: Networks By Design Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$1.00
|
| Rate for Payer: Prime Health Services Commercial |
$1.84
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.71
|
|
|
GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [15911]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
|
|
GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [15911]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$13.17 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GENTAMICIN ORAL SOLUTION (IV FORM) 10 MG/ML [4080431]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 9994-0804-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
|
GENTAMICIN ORAL SOLUTION (IV FORM) 10 MG/ML [4080431]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 9994-0804-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.47
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
GENTAMICIN (PF) 20 MG/2 ML MED NEB [4080723]
|
Facility
|
IP
|
$3.70
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO |
$2.59
|
| Rate for Payer: Cigna of CA PPO |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: EPIC Health Plan Senior |
$1.48
|
| Rate for Payer: Galaxy Health WC |
$3.15
|
| Rate for Payer: Global Benefits Group Commercial |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$1.85
|
| Rate for Payer: Prime Health Services Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.21
|
|
|
GENTAMICIN (PF) 20 MG/2 ML MED NEB [4080723]
|
Facility
|
OP
|
$3.70
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$13.17 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO |
$2.59
|
| Rate for Payer: Cigna of CA PPO |
$2.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: EPIC Health Plan Senior |
$1.48
|
| Rate for Payer: Galaxy Health WC |
$3.15
|
| Rate for Payer: Global Benefits Group Commercial |
$2.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$1.85
|
| Rate for Payer: Prime Health Services Commercial |
$3.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Vantage Medical Group Senior |
$3.15
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [119249]
|
Facility
|
OP
|
$3.70
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$13.17 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO |
$2.59
|
| Rate for Payer: Cigna of CA PPO |
$2.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: EPIC Health Plan Senior |
$1.48
|
| Rate for Payer: Galaxy Health WC |
$3.15
|
| Rate for Payer: Global Benefits Group Commercial |
$2.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.59
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$1.85
|
| Rate for Payer: Prime Health Services Commercial |
$3.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Vantage Medical Group Senior |
$3.15
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [119249]
|
Facility
|
IP
|
$3.70
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO |
$2.59
|
| Rate for Payer: Cigna of CA PPO |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: EPIC Health Plan Senior |
$1.48
|
| Rate for Payer: Galaxy Health WC |
$3.15
|
| Rate for Payer: Global Benefits Group Commercial |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$1.85
|
| Rate for Payer: Prime Health Services Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.21
|
|
|
GENTIAN VIOLET 1 % TOPICAL SOLUTION [3430]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 8770140073
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
GENTIAN VIOLET 1 % TOPICAL SOLUTION [3430]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 8770140073
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
GLIMEPIRIDE 1 MG TABLET [16355]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 68084-788-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.86
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.86
|
|
|
GLIMEPIRIDE 1 MG TABLET [16355]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 68084-788-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.62
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Senior |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.86
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO |
$0.51
|
| Rate for Payer: United Healthcare HMO Rider |
$0.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Vantage Medical Group Senior |
$0.86
|
|
|
GLIMEPIRIDE 2 MG TABLET [16356]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 68084-326-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
|
|
GLIMEPIRIDE 2 MG TABLET [16356]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 68084-326-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
GLIMEPIRIDE 2 MG TABLET [16356]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 68084-326-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
GLIMEPIRIDE 2 MG TABLET [16356]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 68084-326-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
|
|
GLIMEPIRIDE 4 MG TABLET [16357]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 55111-322-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
GLIMEPIRIDE 4 MG TABLET [16357]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 55111-322-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
