|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0574006930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0574006915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| 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 |
$0.08
|
| 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 |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| 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 |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.38
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.55
|
| Rate for Payer: Blue Shield of California EPN |
$13.24
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Senior |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.79
|
| Rate for Payer: Heritage Provider Network Senior |
$16.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Senior |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Senior |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.55
|
| Rate for Payer: Blue Shield of California EPN |
$13.24
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Senior |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.79
|
| Rate for Payer: Heritage Provider Network Senior |
$16.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.55
|
| Rate for Payer: Blue Shield of California EPN |
$13.24
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Senior |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.79
|
| Rate for Payer: Heritage Provider Network Senior |
$16.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Senior |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Senior |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Senior |
$18.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.55
|
| Rate for Payer: Blue Shield of California EPN |
$13.24
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Senior |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.79
|
| Rate for Payer: Heritage Provider Network Senior |
$16.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.85
|
| Rate for Payer: TriValley Medical Group Senior |
$10.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$23.06 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.55
|
| Rate for Payer: Blue Shield of California EPN |
$13.24
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.06
|
| Rate for Payer: Dignity Health Senior |
$23.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.79
|
| Rate for Payer: Heritage Provider Network Senior |
$16.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.99
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.85
|
| Rate for Payer: TriValley Medical Group Senior |
$10.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 72241-039-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| 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: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 72241-039-05
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 0093-8343-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 23155-057-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 23155-057-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 0093-8343-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
GLYBURIDE 5 MG-METFORMIN 500 MG TABLET [28725]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 23155-235-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| 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 |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
GLYBURIDE 5 MG-METFORMIN 500 MG TABLET [28725]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 23155-235-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| 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 |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| 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 Commercial |
$0.14
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 23155-058-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.21
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.27
|
| 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: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
