|
GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]
|
Facility
|
IP
|
$336.00
|
|
|
Service Code
|
CPT J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.64 |
| Max. Negotiated Rate |
$285.60 |
| Rate for Payer: Blue Shield of California Commercial |
$239.23
|
| Rate for Payer: Blue Shield of California EPN |
$172.03
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO |
$235.20
|
| Rate for Payer: Cigna of CA PPO |
$235.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$134.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$134.40
|
| Rate for Payer: Galaxy Health WC |
$285.60
|
| Rate for Payer: Global Benefits Group Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$224.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.64
|
| Rate for Payer: Multiplan Commercial |
$268.80
|
| Rate for Payer: Networks By Design Commercial |
$168.00
|
| Rate for Payer: Prime Health Services Commercial |
$285.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$126.87
|
| Rate for Payer: United Healthcare All Other HMO |
$123.92
|
| Rate for Payer: United Healthcare HMO Rider |
$121.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$110.88
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]
|
Facility
|
OP
|
$336.00
|
|
|
Service Code
|
CPT J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.64 |
| Max. Negotiated Rate |
$1,184.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,184.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$235.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.65
|
| Rate for Payer: Blue Distinction Transplant |
$201.60
|
| Rate for Payer: Blue Shield of California Commercial |
$247.63
|
| Rate for Payer: Blue Shield of California EPN |
$201.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO |
$235.20
|
| Rate for Payer: Cigna of CA PPO |
$235.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.55
|
| Rate for Payer: Dignity Health Media |
$188.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$254.30
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$188.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$188.37
|
| Rate for Payer: Galaxy Health WC |
$285.60
|
| Rate for Payer: Global Benefits Group Commercial |
$201.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$252.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.92
|
| Rate for Payer: Heritage Provider Network Transplant |
$308.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$305.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$305.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$188.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$224.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$366.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$188.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$237.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$252.41
|
| Rate for Payer: Multiplan Commercial |
$268.80
|
| Rate for Payer: Networks By Design Commercial |
$168.00
|
| Rate for Payer: Prime Health Services Commercial |
$285.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$201.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$201.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$168.00
|
| Rate for Payer: United Healthcare All Other HMO |
$168.00
|
| Rate for Payer: United Healthcare HMO Rider |
$168.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$282.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Vantage Medical Group Senior |
$188.37
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]
|
Facility
|
IP
|
$265.98
|
|
|
Service Code
|
CPT J1611
|
| Hospital Charge Code |
ERX209701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.84 |
| Max. Negotiated Rate |
$226.08 |
| Rate for Payer: Blue Shield of California Commercial |
$189.38
|
| Rate for Payer: Blue Shield of California EPN |
$136.18
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO |
$186.19
|
| Rate for Payer: Cigna of CA PPO |
$186.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$106.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$106.39
|
| Rate for Payer: Galaxy Health WC |
$226.08
|
| Rate for Payer: Global Benefits Group Commercial |
$159.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$177.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.84
|
| Rate for Payer: Multiplan Commercial |
$212.78
|
| Rate for Payer: Networks By Design Commercial |
$132.99
|
| Rate for Payer: Prime Health Services Commercial |
$226.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$100.43
|
| Rate for Payer: United Healthcare All Other HMO |
$98.09
|
| Rate for Payer: United Healthcare HMO Rider |
$95.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$87.77
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]
|
Facility
|
OP
|
$265.98
|
|
|
Service Code
|
CPT J1611
|
| Hospital Charge Code |
ERX209701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.84 |
| Max. Negotiated Rate |
$778.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$778.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$154.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$136.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$136.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.36
|
| Rate for Payer: Blue Distinction Transplant |
$159.59
|
| Rate for Payer: Blue Shield of California Commercial |
$196.03
|
| Rate for Payer: Blue Shield of California EPN |
$155.33
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO |
$186.19
|
| Rate for Payer: Cigna of CA PPO |
$186.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$185.74
|
| Rate for Payer: Dignity Health Media |
$123.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$167.17
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$123.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$123.83
|
| Rate for Payer: Galaxy Health WC |
$226.08
|
| Rate for Payer: Global Benefits Group Commercial |
$159.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$199.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.08
|
| Rate for Payer: Heritage Provider Network Transplant |
$203.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$200.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$200.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$123.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$177.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$243.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$123.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$156.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$165.93
|
| Rate for Payer: Multiplan Commercial |
$212.78
|
| Rate for Payer: Networks By Design Commercial |
$132.99
|
| Rate for Payer: Prime Health Services Commercial |
$226.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$159.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$159.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$132.99
|
| Rate for Payer: United Healthcare All Other HMO |
$132.99
|
| Rate for Payer: United Healthcare HMO Rider |
$132.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$132.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$185.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.21
|
| Rate for Payer: Vantage Medical Group Senior |
$123.83
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET [16050]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 8770142600
|
| Hospital Charge Code |
ERX16050
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET [16050]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 8770142600
|
| Hospital Charge Code |
ERX16050
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Distinction Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Media |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 574006945
|
| Hospital Charge Code |
NDG27466B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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: 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: 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
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
1772070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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: 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: 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
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 574006945
|
| Hospital Charge Code |
NDG27466B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| 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: 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
|
| 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
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
1772070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| 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: 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
|
| 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
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 574006915
|
| Hospital Charge Code |
1772070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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: 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: 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
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 574006915
|
| Hospital Charge Code |
1772070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| 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: 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
|
| 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
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 9468804230
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Distinction Transplant |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Media |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 94688-0142-30
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Distinction Transplant |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Media |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 94688-0142-30
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 9468804230
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
ERX205214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
ERX205214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.35
|
| Rate for Payer: Blue Distinction Transplant |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$1.45
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Media |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
13713B
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
13713B
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$19.99
|
| Rate for Payer: Blue Shield of California EPN |
$15.84
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Cigna of CA HMO |
$17.36
|
| Rate for Payer: Cigna of CA PPO |
$20.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.56
|
| Rate for Payer: United Healthcare All Other HMO |
$13.56
|
| Rate for Payer: United Healthcare HMO Rider |
$13.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
NDG13713E
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$19.99
|
| Rate for Payer: Blue Shield of California EPN |
$15.84
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Cigna of CA HMO |
$17.36
|
| Rate for Payer: Cigna of CA PPO |
$20.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.56
|
| Rate for Payer: United Healthcare All Other HMO |
$13.56
|
| Rate for Payer: United Healthcare HMO Rider |
$13.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
NDG13713E
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
NDG13713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$19.99
|
| Rate for Payer: Blue Shield of California EPN |
$15.84
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Cigna of CA HMO |
$17.36
|
| Rate for Payer: Cigna of CA PPO |
$20.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.56
|
| Rate for Payer: United Healthcare All Other HMO |
$13.56
|
| Rate for Payer: United Healthcare HMO Rider |
$13.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
NDG13713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-15
|
| Hospital Charge Code |
NDC13713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Blue Shield of California Commercial |
$19.32
|
| Rate for Payer: Blue Shield of California EPN |
$13.89
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Cigna of CA HMO |
$18.99
|
| Rate for Payer: Cigna of CA PPO |
$18.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$21.70
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
|
