|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
1772070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 9468804230
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Distinction Transplant |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Media |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Riverside University Health System MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 9468804230
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 94688-0142-30
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 94688-0142-30
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Distinction Transplant |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Media |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.87
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.23
|
| Rate for Payer: Riverside University Health System MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
ERX205214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
ERX205214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Blue Distinction Transplant |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| Rate for Payer: Cigna of CA HMO |
$1.45
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Media |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
| Rate for Payer: Riverside University Health System MISP |
$0.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
13713B
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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 (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
NDG13713E
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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 (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
NDG13713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| 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 |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.03
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$17.06
|
| Rate for Payer: Blue Shield of California EPN |
$13.27
|
| 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 Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
NDG13713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Central Health Plan Commercial |
$21.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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 (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
13713B
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| 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 |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.03
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$17.06
|
| Rate for Payer: Blue Shield of California EPN |
$13.27
|
| 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 Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
NDG13713E
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| 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 |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.03
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$17.06
|
| Rate for Payer: Blue Shield of California EPN |
$13.27
|
| 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 Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
NDG13713D
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Blue Shield of California Commercial |
$20.35
|
| Rate for Payer: Blue Shield of California EPN |
$14.49
|
| 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: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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 9999-0137-15
|
| Hospital Charge Code |
NDC13713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| 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 |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.03
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$17.06
|
| Rate for Payer: Blue Shield of California EPN |
$13.27
|
| 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 Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
NDG13713D
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| 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 |
$14.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.03
|
| Rate for Payer: Blue Distinction Transplant |
$16.28
|
| Rate for Payer: Blue Shield of California Commercial |
$17.06
|
| Rate for Payer: Blue Shield of California EPN |
$13.27
|
| 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 Media |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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
|
| 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 Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-15
|
| Hospital Charge Code |
NDC13713
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$24.42 |
| Rate for Payer: Blue Shield of California Commercial |
$20.35
|
| Rate for Payer: Blue Shield of California EPN |
$14.49
|
| 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: EPIC Health Plan Commercial |
$10.85
|
| Rate for Payer: Galaxy Health WC |
$23.06
|
| Rate for Payer: Global Benefits Group Commercial |
$16.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$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
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
1711409
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Distinction Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Media |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
1711409
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 0093-8343-01
|
| Hospital Charge Code |
1711344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.10
|
| 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 Distinction Transplant |
$0.11
|
| 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 |
$0.09
|
| 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 Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| 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
|
| 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 Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 23155-057-01
|
| Hospital Charge Code |
1711344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| 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
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 23155-057-01
|
| Hospital Charge Code |
1711344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.13
|
| 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 Distinction Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| 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: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| 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
|
| 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 Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 0093-8343-01
|
| Hospital Charge Code |
1711344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| 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 5 MG-METFORMIN 500 MG TABLET [28725]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 23155-235-01
|
| Hospital Charge Code |
1710923
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.16
|
| 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 Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| 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 Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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
|
| 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 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 23155-235-01
|
| Hospital Charge Code |
1710923
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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
|
|
