|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.94 |
| Max. Negotiated Rate |
$36.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$29.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$29.39
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$29.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$29.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$36.74
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.94 |
| Max. Negotiated Rate |
$39.19 |
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$29.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$36.74
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
|
OP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.74 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.17
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.46
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
|
IP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.74 |
| Max. Negotiated Rate |
$22.89 |
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.46
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.37 |
| Max. Negotiated Rate |
$27.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$22.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$22.22
|
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$22.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$27.77
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
IP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.33 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.36
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.33 |
| Max. Negotiated Rate |
$26.36 |
| Rate for Payer: Health Smart Auto/Commercial |
$21.08
|
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.36
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
IP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.37 |
| Max. Negotiated Rate |
$29.62 |
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$27.77
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$27.50
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
ERX214049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.50
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.62
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$27.50
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
ERX214049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.62
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
NDG214044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.12
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
NDG214044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.30
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.12
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
OP
|
$14.15
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG214043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$10.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.49
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.61
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
IP
|
$14.15
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG214043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.61
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$27.50
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
ERX214047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.62
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$27.50
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
ERX214047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.50
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.62
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
OP
|
$100.56
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.31 |
| Max. Negotiated Rate |
$75.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$60.34
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$75.41
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$75.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$75.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$75.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$60.34
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$75.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$75.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$60.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.42
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
IP
|
$100.56
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.31 |
| Max. Negotiated Rate |
$80.45 |
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$100.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$100.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$94.27
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.52
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.61
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.52
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.38
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.98
|
|
|
BROMPHENIRAMINE-PHENYLEPHRINE 1 MG-2.5 MG/5 ML ORAL SOLUTION [77434]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 49348-777-34
|
| Hospital Charge Code |
NDG77434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
