|
GLUCAGON 1 MG/ML SOLUTION FOR INJECTION [121354]
|
Facility
OP
|
$205.92
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
ERX121354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.27 |
| Max. Negotiated Rate |
$462.75 |
| Rate for Payer: Adventist Health Commercial |
$41.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$462.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$141.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$235.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$207.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.88
|
| Rate for Payer: Blue Shield of California Commercial |
$173.91
|
| Rate for Payer: Blue Shield of California EPN |
$173.91
|
| Rate for Payer: Cash Price |
$92.66
|
| Rate for Payer: Cash Price |
$92.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.20
|
| Rate for Payer: Dignity Health Senior |
$207.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$188.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$95.34
|
| Rate for Payer: Heritage Provider Network Senior |
$95.34
|
| Rate for Payer: Humana Medicare |
$188.37
|
| Rate for Payer: IEHP Medi-Cal |
$300.81
|
| Rate for Payer: IEHP Medicare Advantage |
$188.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$357.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$222.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$237.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$237.34
|
| Rate for Payer: Multiplan Commercial |
$154.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$207.20
|
| Rate for Payer: TriValley Medical Group Senior |
$188.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$75.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$68.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$282.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Vantage Medical Group Senior |
$188.37
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]
|
Facility
OP
|
$336.00
|
|
|
Service Code
|
CPT J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.82 |
| Max. Negotiated Rate |
$462.75 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$462.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$235.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$207.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.88
|
| Rate for Payer: Blue Shield of California Commercial |
$173.91
|
| Rate for Payer: Blue Shield of California EPN |
$173.91
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$282.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.20
|
| Rate for Payer: Dignity Health Senior |
$207.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$188.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$155.57
|
| Rate for Payer: Heritage Provider Network Senior |
$155.57
|
| Rate for Payer: Humana Medicare |
$188.37
|
| Rate for Payer: IEHP Medi-Cal |
$300.81
|
| Rate for Payer: IEHP Medicare Advantage |
$188.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$357.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$222.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$237.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$237.34
|
| Rate for Payer: Multiplan Commercial |
$252.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$207.20
|
| Rate for Payer: TriValley Medical Group Senior |
$188.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$122.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$112.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$282.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.20
|
| Rate for Payer: Vantage Medical Group Senior |
$188.37
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]
|
Facility
IP
|
$336.00
|
|
|
Service Code
|
CPT J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.82 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Adventist Health Commercial |
$67.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$230.83
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$154.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$181.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$227.47
|
| Rate for Payer: Heritage Provider Network Senior |
$227.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.00
|
| Rate for Payer: Multiplan Commercial |
$252.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$122.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$112.26
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]
|
Facility
OP
|
$265.98
|
|
|
Service Code
|
CPT J1611
|
| Hospital Charge Code |
ERX209701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$355.29 |
| Rate for Payer: Adventist Health Commercial |
$53.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$304.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$154.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$136.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$136.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$355.29
|
| Rate for Payer: Blue Shield of California Commercial |
$169.58
|
| Rate for Payer: Blue Shield of California EPN |
$169.58
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$122.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$185.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$136.21
|
| Rate for Payer: Dignity Health Senior |
$136.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$170.23
|
| Rate for Payer: EPIC Health Plan Medicare |
$123.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.15
|
| Rate for Payer: Heritage Provider Network Senior |
$123.15
|
| Rate for Payer: Humana Medicare |
$123.83
|
| Rate for Payer: IEHP Medi-Cal |
$200.13
|
| Rate for Payer: IEHP Medicare Advantage |
$123.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$235.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$146.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$156.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$156.03
|
| Rate for Payer: Multiplan Commercial |
$199.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$136.21
|
| Rate for Payer: TriValley Medical Group Senior |
$123.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$185.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$136.21
|
| Rate for Payer: Vantage Medical Group Senior |
$123.83
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]
|
Facility
IP
|
$265.98
|
|
|
Service Code
|
CPT J1611
|
| Hospital Charge Code |
ERX209701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$199.48 |
| Rate for Payer: Adventist Health Commercial |
$53.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.73
|
| Rate for Payer: Cash Price |
$119.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$122.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$143.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.07
|
| Rate for Payer: Heritage Provider Network Senior |
$180.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.50
|
| Rate for Payer: Multiplan Commercial |
$199.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.86
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET [16050]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 8770142600
|
| Hospital Charge Code |
ERX16050
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| 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 Commercial |
$0.06
|
| 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 |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET [16050]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 8770142600
|
| Hospital Charge Code |
ERX16050
|
|
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 Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| 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 |
$0.09
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
1772070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: 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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare 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 |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 574006915
|
| Hospital Charge Code |
1772070
|
|
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: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 574006915
|
| Hospital Charge Code |
1772070
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare 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 |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 574006945
|
| Hospital Charge Code |
NDG27466B
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare 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 |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 574006945
|
| Hospital Charge Code |
NDG27466B
|
|
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: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| 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
IP
|
$0.10
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
1772070
|
|
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: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| 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
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
IP
|
$1.45
|
|
|
Service Code
|
NDC 9468804230
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
OP
|
$1.45
|
|
|
Service Code
|
NDC 94688-0142-30
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: Dignity Health Senior |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
IP
|
$1.45
|
|
|
Service Code
|
NDC 94688-0142-30
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
GLUTAMINE 10 GRAM ORAL POWDER PACKET [120375]
|
Facility
OP
|
$1.45
|
|
|
Service Code
|
NDC 9468804230
|
| Hospital Charge Code |
ERX120375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.23
|
| Rate for Payer: Dignity Health Senior |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Vantage Medical Group Senior |
$1.23
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
ERX205214
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| 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 |
ERX205214
|
|
Hospital Revenue Code
|
271
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| 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 |
$1.48
|
| 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 |
$1.09
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
13713B
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$5.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Cash Price |
$12.21
|
| 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 |
NDG13713
|
|
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: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Cash Price |
$12.21
|
| 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 3877924718
|
| Hospital Charge Code |
13713B
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.85
|
| Rate for Payer: Blue Shield of California EPN |
$15.93
|
| Rate for Payer: Cash Price |
$12.21
|
| 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 |
$13.08
|
| 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
|
| 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 |
NDG13713E
|
|
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: Aetna of CA Non-Gatekeeper |
$18.64
|
| Rate for Payer: Cash Price |
$12.21
|
| 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 3877924719
|
| Hospital Charge Code |
NDG13713
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.85
|
| Rate for Payer: Blue Shield of California EPN |
$15.93
|
| Rate for Payer: Cash Price |
$12.21
|
| 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 |
$13.08
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
NDG13713E
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$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: AlphaCare Medical Group Commercial/Exchange |
$23.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.85
|
| Rate for Payer: Blue Shield of California EPN |
$15.93
|
| Rate for Payer: Cash Price |
$12.21
|
| 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 |
$13.08
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.06
|
| Rate for Payer: Vantage Medical Group Senior |
$23.06
|
|
