|
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: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| 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 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 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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| 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 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
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
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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| 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 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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| 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
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 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: AlphaCare Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.87
|
| 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
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: AlphaCare Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.87
|
| 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 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: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.35
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.36
|
| 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 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 (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 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: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$16.28
|
| 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 (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: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$16.28
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$16.28
|
| 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 (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
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
NDG13713D
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: BCBS Transplant 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 |
$18.99
|
| Rate for Payer: Cigna of CA PPO |
$18.99
|
| 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$16.28
|
| 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 (UD) ORAL POWDER [4089100]
|
Facility
OP
|
$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: Aetna of CA HMO/PPO |
$17.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.16
|
| Rate for Payer: BCBS Transplant 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 |
$18.99
|
| Rate for Payer: Cigna of CA PPO |
$18.99
|
| 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$16.28
|
| 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 (UD) ORAL POWDER [4089100]
|
Facility
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
NDG13713D
|
|
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
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
1711409
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
