|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
NDC 70700-166-22
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.23
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Senior |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.43
|
|
|
GLYCOPYRROLATE 0.2 MG/ML MED NEB SOLUTION [192223]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 0517-4601-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.70
|
| Rate for Payer: Blue Shield of California Commercial |
$9.69
|
| Rate for Payer: Blue Shield of California EPN |
$9.16
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.66
|
| Rate for Payer: Heritage Provider Network Senior |
$9.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.24
|
| Rate for Payer: TriValley Medical Group Senior |
$6.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
GLYCOPYRROLATE 0.2 MG/ML MED NEB SOLUTION [192223]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 0517-4601-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.72
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.56
|
| Rate for Payer: Heritage Provider Network Senior |
$10.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: Dignity Health Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| 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: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Senior |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Senior |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: Dignity Health Senior |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Senior |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Senior |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.63
|
| Rate for Payer: Heritage Provider Network Senior |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Senior |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.81
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
IP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.56 |
| Max. Negotiated Rate |
$449.82 |
| Rate for Payer: Adventist Health Commercial |
$119.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$412.04
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$275.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$323.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$406.04
|
| Rate for Payer: Heritage Provider Network Senior |
$406.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.94
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$218.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$200.38
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.56 |
| Max. Negotiated Rate |
$509.80 |
| Rate for Payer: Adventist Health Commercial |
$119.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$320.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$412.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$509.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$329.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$449.82
|
| Rate for Payer: Blue Shield of California Commercial |
$372.45
|
| Rate for Payer: Blue Shield of California EPN |
$352.06
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$275.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$509.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$509.80
|
| Rate for Payer: Dignity Health Senior |
$509.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$383.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.69
|
| Rate for Payer: Heritage Provider Network Senior |
$277.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$289.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.94
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$239.90
|
| Rate for Payer: TriValley Medical Group Senior |
$239.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$218.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$200.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$509.80
|
| Rate for Payer: Vantage Medical Group Senior |
$509.80
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.76 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$659.52
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$441.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$518.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$649.92
|
| Rate for Payer: Heritage Provider Network Senior |
$649.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$350.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$320.74
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$387.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$659.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$182.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$341.94
|
| Rate for Payer: Blue Shield of California Commercial |
$163.20
|
| Rate for Payer: Blue Shield of California EPN |
$163.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$441.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$207.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.82
|
| Rate for Payer: Dignity Health Senior |
$182.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$614.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$166.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$444.48
|
| Rate for Payer: Heritage Provider Network Senior |
$444.48
|
| Rate for Payer: Humana Medicare |
$166.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$256.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$166.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$315.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$196.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$209.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$209.41
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$384.00
|
| Rate for Payer: TriValley Medical Group Senior |
$384.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$350.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$320.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: Vantage Medical Group Senior |
$182.82
|
|
|
Goniotomy
|
Facility
|
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 65820
|
| Min. Negotiated Rate |
$131.84 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$131.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
IP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.44 |
| Max. Negotiated Rate |
$2,173.10 |
| Rate for Payer: Adventist Health Commercial |
$579.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,990.56
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,332.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,564.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,961.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1,961.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$524.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$724.37
|
| Rate for Payer: Multiplan Commercial |
$2,173.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,056.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$968.04
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
OP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$524.44 |
| Max. Negotiated Rate |
$2,173.10 |
| Rate for Payer: Adventist Health Commercial |
$579.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,199.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,990.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$930.13
|
| Rate for Payer: Blue Shield of California Commercial |
$773.14
|
| Rate for Payer: Blue Shield of California EPN |
$773.14
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,332.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: Dignity Health Senior |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,854.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$609.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,341.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1,341.53
|
| Rate for Payer: Humana Medicare |
$609.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$950.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$609.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$524.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$718.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$724.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$767.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$767.35
|
| Rate for Payer: Multiplan Commercial |
$2,173.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,158.99
|
| Rate for Payer: TriValley Medical Group Senior |
$1,158.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,056.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$968.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
IP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.05 |
| Max. Negotiated Rate |
$775.07 |
| Rate for Payer: Adventist Health Commercial |
$206.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$709.97
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$475.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$558.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$699.63
|
| Rate for Payer: Heritage Provider Network Senior |
$699.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$187.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$258.36
|
| Rate for Payer: Multiplan Commercial |
$775.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$376.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$345.27
|
|
