|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999013714
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.48
|
| 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 |
$20.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.78
|
| Rate for Payer: Blue Shield of California Commercial |
$17.20
|
| Rate for Payer: Blue Shield of California EPN |
$10.82
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Senior |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
| Rate for Payer: Riverside University Health System MISP |
$10.85
|
| 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 9999013713
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Blue Shield of California Commercial |
$21.76
|
| Rate for Payer: Blue Shield of California EPN |
$13.67
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| Rate for Payer: Cigna of CA HMO |
$18.99
|
| Rate for Payer: Cigna of CA PPO |
$18.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Senior |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| 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 9999013715
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Blue Shield of California Commercial |
$21.76
|
| Rate for Payer: Blue Shield of California EPN |
$13.67
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| Rate for Payer: Cigna of CA HMO |
$18.99
|
| Rate for Payer: Cigna of CA PPO |
$18.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Senior |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| 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 9999013715
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.48
|
| 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 |
$20.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.78
|
| Rate for Payer: Blue Shield of California Commercial |
$17.20
|
| Rate for Payer: Blue Shield of California EPN |
$10.82
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Senior |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
| Rate for Payer: Riverside University Health System MISP |
$10.85
|
| 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 9999013713
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.48
|
| 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 |
$20.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.78
|
| Rate for Payer: Blue Shield of California Commercial |
$17.20
|
| Rate for Payer: Blue Shield of California EPN |
$10.82
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Senior |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$17.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: Networks By Design Commercial |
$17.63
|
| Rate for Payer: Prime Health Services Commercial |
$23.06
|
| Rate for Payer: Riverside University Health System MISP |
$10.85
|
| 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
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 0093947753
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 0093947753
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 0093834301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 2315505701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 7224103905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| 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 |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 7224103905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.12
|
| 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 |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| 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 |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 2315505701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 0093834301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
GLYBURIDE 5 MG-METFORMIN 500 MG TABLET [28725]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 2315523501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
GLYBURIDE 5 MG-METFORMIN 500 MG TABLET [28725]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 2315523501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Central Health Plan Commercial |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 2315505801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 2315505801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Riverside University Health System MISP |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
GLYBURIDE ORAL SOLUTION COMPOUND 0.5 MG/ML [4080401]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 9994080401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
|
|
GLYBURIDE ORAL SOLUTION COMPOUND 0.5 MG/ML [4080401]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 9994080401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
GLYBURIDE ORAL SUSPENSION COMPOUND 1 MG/ML [40892026]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 9940892026
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
|
|
GLYBURIDE ORAL SUSPENSION COMPOUND 1 MG/ML [40892026]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 9940892026
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO |
$0.61
|
| Rate for Payer: United Healthcare HMO Rider |
$0.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [117995]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0395103116
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [117995]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 8770140065
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [117995]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 8770140065
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [117995]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0395103116
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
