|
GLYCERIN (CHILD) RECTAL SUPPOSITORY [3492]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 8770142512
|
| Hospital Charge Code |
1748072
|
|
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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| 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 |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
GLYCERIN (CHILD) RECTAL SUPPOSITORY [3492]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0132-0081-12
|
| Hospital Charge Code |
1748072
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
GLYCERIN (CHILD) RECTAL SUPPOSITORY [3492]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0132-0081-12
|
| Hospital Charge Code |
1748072
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECTAL SOLUTION [120948]
|
Facility
IP
|
$0.23
|
|
|
Service Code
|
NDC 0132-0190-12
|
| Hospital Charge Code |
1719212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 |
$0.17
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECTAL SOLUTION [120948]
|
Facility
OP
|
$0.23
|
|
|
Service Code
|
NDC 0132-0190-12
|
| Hospital Charge Code |
1719212
|
|
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 |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| 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 |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| 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: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$3.36
|
|
|
Service Code
|
NDC 0781-3825-71
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$13.80
|
|
|
Service Code
|
NDC 0517-4602-25
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$11.73 |
| Rate for Payer: Adventist Health Commercial |
$2.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.35
|
| Rate for Payer: Blue Shield of California Commercial |
$8.57
|
| Rate for Payer: Blue Shield of California EPN |
$8.10
|
| Rate for Payer: Cash Price |
$6.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.73
|
| Rate for Payer: Dignity Health Senior |
$11.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.54
|
| Rate for Payer: Heritage Provider Network Senior |
$8.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$10.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.73
|
| Rate for Payer: Vantage Medical Group Senior |
$11.73
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$3.12
|
|
|
Service Code
|
NDC 0143-9682-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Senior |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.34
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$3.22
|
|
|
Service Code
|
NDC 16729-471-08
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.21
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Senior |
$2.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.22
|
|
|
Service Code
|
NDC 16729-471-08
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.74
|
| Rate for Payer: Dignity Health Senior |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.74
|
| Rate for Payer: Vantage Medical Group Senior |
$2.74
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$13.80
|
|
|
Service Code
|
NDC 0517-4602-25
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Adventist Health Commercial |
$2.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.48
|
| Rate for Payer: Cash Price |
$6.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.34
|
| Rate for Payer: Heritage Provider Network Senior |
$9.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$10.35
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.24
|
|
|
Service Code
|
NDC 70700-166-22
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.90
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.75
|
| Rate for Payer: Dignity Health Senior |
$2.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Senior |
$2.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Vantage Medical Group Senior |
$2.75
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$3.24
|
|
|
Service Code
|
NDC 70700-166-22
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.23
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Senior |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.43
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$3.36
|
|
|
Service Code
|
NDC 0781-3825-96
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.36
|
|
|
Service Code
|
NDC 0781-3825-71
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Senior |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$1.92
|
|
|
Service Code
|
NDC 71839-125-01
|
| Hospital Charge Code |
1721139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$10.56
|
|
|
Service Code
|
NDC 0517-4605-25
|
| Hospital Charge Code |
1721139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$7.92 |
| Rate for Payer: Adventist Health Commercial |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.25
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.15
|
| Rate for Payer: Heritage Provider Network Senior |
$7.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$10.56
|
|
|
Service Code
|
NDC 0517-4605-25
|
| Hospital Charge Code |
1721139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Adventist Health Commercial |
$2.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.92
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California EPN |
$6.20
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.98
|
| Rate for Payer: Dignity Health Senior |
$8.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.54
|
| Rate for Payer: Heritage Provider Network Senior |
$6.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$7.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.98
|
| Rate for Payer: Vantage Medical Group Senior |
$8.98
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$1.92
|
|
|
Service Code
|
NDC 71839-125-01
|
| Hospital Charge Code |
1721139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$1.92
|
|
|
Service Code
|
NDC 71839-125-25
|
| Hospital Charge Code |
1721139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$1.92
|
|
|
Service Code
|
NDC 71839-125-25
|
| Hospital Charge Code |
1721139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.12
|
|
|
Service Code
|
NDC 0143-9682-25
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.83
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.65
|
| Rate for Payer: Dignity Health Senior |
$2.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.93
|
| Rate for Payer: Heritage Provider Network Senior |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2.65
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
IP
|
$3.12
|
|
|
Service Code
|
NDC 0143-9681-01
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Senior |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.34
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.12
|
|
|
Service Code
|
NDC 0143-9681-01
|
| Hospital Charge Code |
NDG3497
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.83
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.65
|
| Rate for Payer: Dignity Health Senior |
$2.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.93
|
| Rate for Payer: Heritage Provider Network Senior |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2.65
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]
|
Facility
OP
|
$3.22
|
|
|
Service Code
|
NDC 16729-471-63
|
| Hospital Charge Code |
1720491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.89
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.74
|
| Rate for Payer: Dignity Health Senior |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.74
|
| Rate for Payer: Vantage Medical Group Senior |
$2.74
|
|
