|
GLIPIZIDE 5 MG TABLET [10117]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 51079-810-01
|
| Hospital Charge Code |
1711376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
GLIPIZIDE 5 MG TABLET [10117]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 51079-810-20
|
| Hospital Charge Code |
1711376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
GLIPIZIDE 5 MG TABLET [10117]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 51079-810-20
|
| Hospital Charge Code |
1711376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| 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: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Senior |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 59651-270-01
|
| Hospital Charge Code |
1710894
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 59651-270-01
|
| Hospital Charge Code |
1710894
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 64980-281-01
|
| Hospital Charge Code |
1710894
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 64980-281-01
|
| Hospital Charge Code |
1710894
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 59651-268-30
|
| Hospital Charge Code |
1711811
|
|
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 Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 59651-268-30
|
| Hospital Charge Code |
1711811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 64980-279-03
|
| Hospital Charge Code |
1711811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 64980-279-03
|
| Hospital Charge Code |
1711811
|
|
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 Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 68084-111-11
|
| Hospital Charge Code |
1711632
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 68084-111-01
|
| Hospital Charge Code |
1711632
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 68084-111-01
|
| Hospital Charge Code |
1711632
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 68084-111-11
|
| Hospital Charge Code |
1711632
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
Glossectomy; less than one-half tongue
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 41120
|
| Min. Negotiated Rate |
$526.19 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$526.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Glossectomy; partial, with unilateral radical neck dissection
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 41135
|
| Min. Negotiated Rate |
$1,710.42 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,559.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,710.42
|
|
|
GLUCAGON 1 MG INJ SOLUTION. [408121354]
|
Facility
|
IP
|
$265.98
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
1720502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$199.48 |
| Rate for Payer: Adventist Health Commercial |
$53.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.73
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$122.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$143.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.07
|
| Rate for Payer: Heritage Provider Network Senior |
$180.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.50
|
| Rate for Payer: Multiplan Commercial |
$199.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.86
|
|
|
GLUCAGON 1 MG INJ SOLUTION. [408121354]
|
Facility
|
OP
|
$265.98
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
1720502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$462.75 |
| Rate for Payer: Adventist Health Commercial |
$53.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$462.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$235.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.88
|
| Rate for Payer: Blue Shield of California Commercial |
$173.91
|
| Rate for Payer: Blue Shield of California EPN |
$173.91
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$122.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.20
|
| Rate for Payer: Dignity Health Senior |
$207.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$170.23
|
| Rate for Payer: EPIC Health Plan Medicare |
$188.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.15
|
| Rate for Payer: Heritage Provider Network Senior |
$123.15
|
| Rate for Payer: Humana Medicare |
$188.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$300.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$188.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$357.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$222.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$237.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$237.34
|
| Rate for Payer: Multiplan Commercial |
$199.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$106.39
|
| Rate for Payer: TriValley Medical Group Senior |
$106.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$282.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Vantage Medical Group Senior |
$188.37
|
|
|
GLUCAGON 1 MG/ML SOLUTION FOR INJECTION [121354]
|
Facility
|
IP
|
$205.92
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
ERX121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.27 |
| Max. Negotiated Rate |
$154.44 |
| Rate for Payer: Adventist Health Commercial |
$41.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$141.47
|
| Rate for Payer: Cash Price |
$92.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$111.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.41
|
| Rate for Payer: Heritage Provider Network Senior |
$139.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$154.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$68.80
|
|
|
GLUCAGON 1 MG/ML SOLUTION FOR INJECTION [121354]
|
Facility
|
OP
|
$205.92
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
ERX121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.27 |
| Max. Negotiated Rate |
$462.75 |
| Rate for Payer: Adventist Health Commercial |
$41.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$462.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$141.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$235.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.88
|
| Rate for Payer: Blue Shield of California Commercial |
$173.91
|
| Rate for Payer: Blue Shield of California EPN |
$173.91
|
| Rate for Payer: Cash Price |
$92.66
|
| Rate for Payer: Cash Price |
$92.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.20
|
| Rate for Payer: Dignity Health Senior |
$207.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$188.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$95.34
|
| Rate for Payer: Heritage Provider Network Senior |
$95.34
|
| Rate for Payer: Humana Medicare |
$188.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$300.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$188.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$357.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$222.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$237.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$237.34
|
| Rate for Payer: Multiplan Commercial |
$154.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$82.37
|
| Rate for Payer: TriValley Medical Group Senior |
$82.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$68.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$282.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Vantage Medical Group Senior |
$188.37
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]
|
Facility
|
OP
|
$336.00
|
|
|
Service Code
|
CPT J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.82 |
| Max. Negotiated Rate |
$462.75 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$462.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$235.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$207.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.88
|
| Rate for Payer: Blue Shield of California Commercial |
$173.91
|
| Rate for Payer: Blue Shield of California EPN |
$173.91
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.20
|
| Rate for Payer: Dignity Health Senior |
$207.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$188.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$155.57
|
| Rate for Payer: Heritage Provider Network Senior |
$155.57
|
| Rate for Payer: Humana Medicare |
$188.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$300.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$188.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$357.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$222.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$237.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$237.34
|
| Rate for Payer: Multiplan Commercial |
$252.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$134.40
|
| Rate for Payer: TriValley Medical Group Senior |
$134.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$122.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$112.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$282.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Vantage Medical Group Senior |
$188.37
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]
|
Facility
|
IP
|
$336.00
|
|
|
Service Code
|
CPT J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.82 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.83
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$181.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$227.47
|
| Rate for Payer: Heritage Provider Network Senior |
$227.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$252.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$122.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$112.26
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]
|
Facility
|
OP
|
$265.98
|
|
|
Service Code
|
CPT J1611
|
| Hospital Charge Code |
ERX209701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$355.29 |
| Rate for Payer: Adventist Health Commercial |
$53.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$304.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$154.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$136.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$136.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$355.29
|
| Rate for Payer: Blue Shield of California Commercial |
$169.58
|
| Rate for Payer: Blue Shield of California EPN |
$169.58
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$122.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$185.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.21
|
| Rate for Payer: Dignity Health Senior |
$136.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$170.23
|
| Rate for Payer: EPIC Health Plan Medicare |
$123.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.15
|
| Rate for Payer: Heritage Provider Network Senior |
$123.15
|
| Rate for Payer: Humana Medicare |
$123.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$200.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$123.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$235.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$146.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$156.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$156.03
|
| Rate for Payer: Multiplan Commercial |
$199.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$106.39
|
| Rate for Payer: TriValley Medical Group Senior |
$106.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$185.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.21
|
| Rate for Payer: Vantage Medical Group Senior |
$123.83
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]
|
Facility
|
IP
|
$265.98
|
|
|
Service Code
|
CPT J1611
|
| Hospital Charge Code |
ERX209701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$199.48 |
| Rate for Payer: Adventist Health Commercial |
$53.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.73
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$122.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$143.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.07
|
| Rate for Payer: Heritage Provider Network Senior |
$180.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.50
|
| Rate for Payer: Multiplan Commercial |
$199.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.86
|
|
