|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.09
|
| 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 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.25
|
| Rate for Payer: Cash Price |
$0.29
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| 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: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| 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
|
$1.30
|
|
|
Service Code
|
NDC 0904-6709-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| 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 |
$0.09
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA 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 |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| 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: 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 |
$0.14
|
| 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
|
$0.52
|
|
|
Service Code
|
NDC 49884-065-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.29
|
| 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
|
$1.30
|
|
|
Service Code
|
NDC 0904-6709-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.51
|
| 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
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 23155-607-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.14
|
| 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
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$1.77
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| 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 |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.50
|
| Rate for Payer: Dignity Health Senior |
$1.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.13
|
| 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 |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1.50
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.51
|
| 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 64980-273-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.51
|
| 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 |
$0.44
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.65
|
| 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: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| 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
|
$0.26
|
|
|
Service Code
|
NDC 23155-607-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| 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 |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 |
$0.12
|
| 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 |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| 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: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.51
|
| 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 |
$0.44
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.65
|
| 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: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| 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
|
IP
|
$1.77
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.20
|
| Rate for Payer: Heritage Provider Network Senior |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
901700029
|
|
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 |
$1.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.45
|
| 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 |
$1.25
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.84
|
| 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: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| 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 |
901700029
|
|
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: Cash Price |
$1.45
|
| 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
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
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: Cash Price |
$329.87
|
| 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 |
$277.69
|
| Rate for Payer: Heritage Provider Network Senior |
$277.69
|
| 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 |
$216.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.58
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$449.82 |
| 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 |
$13.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$103.56
|
| Rate for Payer: Blue Shield of California Commercial |
$40.78
|
| Rate for Payer: Blue Shield of California EPN |
$40.78
|
| Rate for Payer: Cash Price |
$329.87
|
| Rate for Payer: Cash Price |
$329.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$275.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.13
|
| Rate for Payer: Dignity Health Senior |
$12.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$383.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.69
|
| Rate for Payer: Heritage Provider Network Senior |
$277.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$286.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.90
|
| 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 |
$216.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: Vantage Medical Group Senior |
$12.13
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
HCPCS J1429
|
| Hospital Charge Code |
901700025
|
|
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: Cash Price |
$528.00
|
| 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 |
$444.48
|
| Rate for Payer: Heritage Provider Network Senior |
$444.48
|
| 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 |
$346.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$317.86
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
HCPCS J1429
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$513.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$659.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$720.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$414.39
|
| 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 |
$528.00
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$441.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$816.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$816.00
|
| Rate for Payer: Dignity Health Senior |
$816.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$614.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$444.48
|
| Rate for Payer: Heritage Provider Network Senior |
$444.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$266.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$457.92
|
| 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: Molina Healthcare of CA Medi-Cal |
$672.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$672.00
|
| 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 |
$346.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$317.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$816.00
|
| Rate for Payer: Vantage Medical Group Senior |
$816.00
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]
|
Facility
|
OP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$9.18 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.18
|
| Rate for Payer: Dignity Health Senior |
$9.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.56
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.18
|
| Rate for Payer: Vantage Medical Group Senior |
$9.18
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]
|
Facility
|
IP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]
|
Facility
|
OP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$9.18 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.18
|
| Rate for Payer: Dignity Health Senior |
$9.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.56
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.18
|
| Rate for Payer: Vantage Medical Group Senior |
$9.18
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]
|
Facility
|
IP
|
$10.80
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$8.10 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
|
