|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.36
|
|
|
Service Code
|
NDC 0781-3825-71
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.00
|
| Rate for Payer: BCBS Transplant Transplant |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.96
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$2.15
|
| Rate for Payer: Cigna of CA PPO |
$2.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Media |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
GLYCOPYRROLATE 0.2 MG/ML MED NEB SOLUTION [192223]
|
Facility
IP
|
$15.60
|
|
|
Service Code
|
NDC 0517-4601-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Blue Shield of California Commercial |
$11.11
|
| Rate for Payer: Blue Shield of California EPN |
$7.99
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO |
$10.92
|
| Rate for Payer: Cigna of CA PPO |
$10.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$12.48
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
|
|
GLYCOPYRROLATE 0.2 MG/ML MED NEB SOLUTION [192223]
|
Facility
OP
|
$15.60
|
|
|
Service Code
|
NDC 0517-4601-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.29
|
| Rate for Payer: BCBS Transplant Transplant |
$9.36
|
| Rate for Payer: Blue Shield of California Commercial |
$11.50
|
| Rate for Payer: Blue Shield of California EPN |
$9.11
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO |
$10.92
|
| Rate for Payer: Cigna of CA PPO |
$10.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Media |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$12.48
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO |
$7.80
|
| Rate for Payer: United Healthcare HMO Rider |
$7.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| 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 |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| 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 |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
IP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
OP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Galaxy Health WC |
$0.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: BCBS Transplant Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Media |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
IP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
IP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
OP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Media |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
OP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: BCBS Transplant Transplant |
$1.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Media |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO |
$0.89
|
| Rate for Payer: United Healthcare HMO Rider |
$0.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
OP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Media |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
IP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: BCBS Transplant Transplant |
$1.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.57
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Media |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.10
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
OP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.94 |
| Max. Negotiated Rate |
$509.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$393.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$509.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$329.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$329.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$357.34
|
| Rate for Payer: BCBS Transplant Transplant |
$359.86
|
| Rate for Payer: Blue Shield of California Commercial |
$442.02
|
| Rate for Payer: Blue Shield of California EPN |
$350.26
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$509.80
|
| Rate for Payer: Dignity Health Media |
$509.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$509.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$239.90
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$449.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.94
|
| Rate for Payer: Multiplan Commercial |
$479.81
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$359.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$359.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$299.88
|
| Rate for Payer: United Healthcare All Other HMO |
$299.88
|
| Rate for Payer: United Healthcare HMO Rider |
$299.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$299.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$509.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$509.80
|
| Rate for Payer: Vantage Medical Group Senior |
$509.80
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
IP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.94 |
| Max. Negotiated Rate |
$509.80 |
| Rate for Payer: Blue Shield of California Commercial |
$427.03
|
| Rate for Payer: Blue Shield of California EPN |
$307.08
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$239.90
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.94
|
| Rate for Payer: Multiplan Commercial |
$479.81
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
IP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Blue Shield of California Commercial |
$683.52
|
| Rate for Payer: Blue Shield of California EPN |
$491.52
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$640.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$365.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$230.40
|
| Rate for Payer: Multiplan Commercial |
$768.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
OP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.20 |
| Max. Negotiated Rate |
$992.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$992.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$182.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$341.04
|
| Rate for Payer: BCBS Transplant Transplant |
$576.00
|
| Rate for Payer: Blue Shield of California Commercial |
$707.52
|
| Rate for Payer: Blue Shield of California EPN |
$192.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$207.75
|
| Rate for Payer: Dignity Health Media |
$182.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.37
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$166.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$166.20
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$720.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.57
|
| Rate for Payer: Heritage Provider Network Transplant |
$272.57
|
| Rate for Payer: IEHP Medi-Cal |
$269.25
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$269.25
|
| Rate for Payer: IEHP Medicare Advantage |
$166.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$640.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$312.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$230.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$209.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$222.71
|
| Rate for Payer: Multiplan Commercial |
$768.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$576.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$576.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Other HMO |
$480.00
|
| Rate for Payer: United Healthcare HMO Rider |
$480.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$480.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: Vantage Medical Group Senior |
$182.82
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
OP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$609.01 |
| Max. Negotiated Rate |
$2,462.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,199.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$927.69
|
| Rate for Payer: BCBS Transplant Transplant |
$1,738.48
|
| Rate for Payer: Blue Shield of California Commercial |
$2,135.44
|
| Rate for Payer: Blue Shield of California EPN |
$837.77
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO |
$2,028.23
|
| Rate for Payer: Cigna of CA PPO |
$2,028.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Media |
$609.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$822.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$609.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$609.01
|
| Rate for Payer: Galaxy Health WC |
$2,462.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,738.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,173.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$998.77
|
| Rate for Payer: Heritage Provider Network Transplant |
$998.77
|
| Rate for Payer: IEHP Medi-Cal |
$986.59
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$986.59
|
| Rate for Payer: IEHP Medicare Advantage |
$609.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,932.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$609.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$695.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$767.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$816.07
|
| Rate for Payer: Multiplan Commercial |
$2,317.98
|
| Rate for Payer: Networks By Design Commercial |
$1,448.74
|
| Rate for Payer: Prime Health Services Commercial |
$2,462.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,738.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,738.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,448.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1,448.74
|
| Rate for Payer: United Healthcare HMO Rider |
$1,448.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,448.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
IP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$695.39 |
| Max. Negotiated Rate |
$2,462.85 |
| Rate for Payer: Blue Shield of California Commercial |
$2,063.00
|
| Rate for Payer: Blue Shield of California EPN |
$1,483.50
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO |
$2,028.23
|
| Rate for Payer: Cigna of CA PPO |
$2,028.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,158.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,158.99
|
| Rate for Payer: Galaxy Health WC |
$2,462.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,738.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,932.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,103.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$695.39
|
| Rate for Payer: Multiplan Commercial |
$2,317.98
|
| Rate for Payer: Networks By Design Commercial |
$1,448.74
|
| Rate for Payer: Prime Health Services Commercial |
$2,462.85
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
IP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.02 |
| Max. Negotiated Rate |
$878.42 |
| Rate for Payer: Blue Shield of California Commercial |
$735.80
|
| Rate for Payer: Blue Shield of California EPN |
$529.12
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cigna of CA HMO |
$723.40
|
| Rate for Payer: Cigna of CA PPO |
$723.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$413.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$413.37
|
| Rate for Payer: Galaxy Health WC |
$878.42
|
| Rate for Payer: Global Benefits Group Commercial |
$620.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$689.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$393.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$248.02
|
| Rate for Payer: Multiplan Commercial |
$826.74
|
| Rate for Payer: Networks By Design Commercial |
$516.72
|
| Rate for Payer: Prime Health Services Commercial |
$878.42
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
OP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.02 |
| Max. Negotiated Rate |
$1,199.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,199.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$927.69
|
| Rate for Payer: BCBS Transplant Transplant |
$620.06
|
| Rate for Payer: Blue Shield of California Commercial |
$761.64
|
| Rate for Payer: Blue Shield of California EPN |
$837.77
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cigna of CA HMO |
$723.40
|
| Rate for Payer: Cigna of CA PPO |
$723.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Media |
$609.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$822.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$609.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$609.01
|
| Rate for Payer: Galaxy Health WC |
$878.42
|
| Rate for Payer: Global Benefits Group Commercial |
$620.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$775.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$998.77
|
| Rate for Payer: Heritage Provider Network Transplant |
$998.77
|
| Rate for Payer: IEHP Medi-Cal |
$986.59
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$986.59
|
| Rate for Payer: IEHP Medicare Advantage |
$609.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$689.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$609.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$248.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$767.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$816.07
|
| Rate for Payer: Multiplan Commercial |
$826.74
|
| Rate for Payer: Networks By Design Commercial |
$516.72
|
| Rate for Payer: Prime Health Services Commercial |
$878.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$620.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$620.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$516.72
|
| Rate for Payer: United Healthcare All Other HMO |
$516.72
|
| Rate for Payer: United Healthcare HMO Rider |
$516.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$516.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
