|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
OP
|
$17.45
|
|
|
Service Code
|
NDC 68382-446-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Adventist Health Commercial |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.72
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna of CA HMO |
$12.21
|
| Rate for Payer: Cigna of CA PPO |
$12.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: EPIC Health Plan Senior |
$6.98
|
| Rate for Payer: Galaxy Health WC |
$14.83
|
| Rate for Payer: Global Benefits Group Commercial |
$10.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$13.96
|
| Rate for Payer: Networks By Design Commercial |
$11.34
|
| Rate for Payer: Prime Health Services Commercial |
$14.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.72
|
| Rate for Payer: United Healthcare All Other HMO |
$8.72
|
| Rate for Payer: United Healthcare HMO Rider |
$8.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.83
|
| Rate for Payer: Vantage Medical Group Senior |
$14.83
|
|
|
BOSENTAN 62.5 MG TABLET [31875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.66 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Blue Shield of California Commercial |
$197.99
|
| Rate for Payer: Blue Shield of California EPN |
$130.38
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO |
$187.80
|
| Rate for Payer: Cigna of CA PPO |
$187.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.31
|
| Rate for Payer: EPIC Health Plan Senior |
$107.31
|
| Rate for Payer: Galaxy Health WC |
$228.04
|
| Rate for Payer: Global Benefits Group Commercial |
$160.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.39
|
| Rate for Payer: Multiplan Commercial |
$214.62
|
| Rate for Payer: Networks By Design Commercial |
$174.38
|
| Rate for Payer: Prime Health Services Commercial |
$228.04
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.66 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$175.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.75
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO |
$187.80
|
| Rate for Payer: Cigna of CA PPO |
$187.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.31
|
| Rate for Payer: EPIC Health Plan Senior |
$107.31
|
| Rate for Payer: Galaxy Health WC |
$228.04
|
| Rate for Payer: Global Benefits Group Commercial |
$160.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.80
|
| Rate for Payer: Multiplan Commercial |
$214.62
|
| Rate for Payer: Networks By Design Commercial |
$174.38
|
| Rate for Payer: Prime Health Services Commercial |
$228.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$160.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$160.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.14
|
| Rate for Payer: United Healthcare All Other HMO |
$134.14
|
| Rate for Payer: United Healthcare HMO Rider |
$134.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$228.04
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.66 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Blue Shield of California Commercial |
$197.99
|
| Rate for Payer: Blue Shield of California EPN |
$130.38
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO |
$187.80
|
| Rate for Payer: Cigna of CA PPO |
$187.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.31
|
| Rate for Payer: EPIC Health Plan Senior |
$107.31
|
| Rate for Payer: Galaxy Health WC |
$228.04
|
| Rate for Payer: Global Benefits Group Commercial |
$160.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.39
|
| Rate for Payer: Multiplan Commercial |
$214.62
|
| Rate for Payer: Networks By Design Commercial |
$174.38
|
| Rate for Payer: Prime Health Services Commercial |
$228.04
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.66 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$175.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.75
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO |
$187.80
|
| Rate for Payer: Cigna of CA PPO |
$187.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.31
|
| Rate for Payer: EPIC Health Plan Senior |
$107.31
|
| Rate for Payer: Galaxy Health WC |
$228.04
|
| Rate for Payer: Global Benefits Group Commercial |
$160.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.80
|
| Rate for Payer: Multiplan Commercial |
$214.62
|
| Rate for Payer: Networks By Design Commercial |
$174.38
|
| Rate for Payer: Prime Health Services Commercial |
$228.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$160.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$160.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.14
|
| Rate for Payer: United Healthcare All Other HMO |
$134.14
|
| Rate for Payer: United Healthcare HMO Rider |
$134.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$228.04
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.66 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Blue Shield of California Commercial |
$197.99
|
| Rate for Payer: Blue Shield of California EPN |
$130.38
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO |
$187.80
|
| Rate for Payer: Cigna of CA PPO |
$187.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.31
|
| Rate for Payer: EPIC Health Plan Senior |
$107.31
|
| Rate for Payer: Galaxy Health WC |
$228.04
|
| Rate for Payer: Global Benefits Group Commercial |
$160.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.39
|
| Rate for Payer: Multiplan Commercial |
$214.62
|
| Rate for Payer: Networks By Design Commercial |
$174.38
|
| Rate for Payer: Prime Health Services Commercial |
$228.04
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.10
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$13.15
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Blue Shield of California Commercial |
$12.13
|
| Rate for Payer: Blue Shield of California EPN |
$7.99
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cigna of CA HMO |
$11.51
|
| Rate for Payer: Cigna of CA PPO |
$11.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: EPIC Health Plan Senior |
$6.58
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$13.15
|
| Rate for Payer: Networks By Design Commercial |
$10.69
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
OP
|
$214.96
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.99 |
| Max. Negotiated Rate |
$182.72 |
| Rate for Payer: Adventist Health Commercial |
$42.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$140.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$182.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$161.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$132.01
|
| Rate for Payer: Cash Price |
$118.23
|
| Rate for Payer: Cigna of CA HMO |
$150.47
|
| Rate for Payer: Cigna of CA PPO |
$150.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$182.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$182.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.98
|
| Rate for Payer: EPIC Health Plan Senior |
$85.98
|
| Rate for Payer: Galaxy Health WC |
$182.72
|
| Rate for Payer: Global Benefits Group Commercial |
$128.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$143.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$150.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$150.47
|
| Rate for Payer: Multiplan Commercial |
$171.97
|
| Rate for Payer: Networks By Design Commercial |
$139.72
|
| Rate for Payer: Prime Health Services Commercial |
$182.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$128.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$128.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$107.48
|
| Rate for Payer: United Healthcare All Other HMO |
$107.48
|
| Rate for Payer: United Healthcare HMO Rider |
$107.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$107.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$182.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.72
|
| Rate for Payer: Vantage Medical Group Senior |
$182.72
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
IP
|
$214.96
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.99 |
| Max. Negotiated Rate |
$182.72 |
| Rate for Payer: Adventist Health Commercial |
$42.99
|
| Rate for Payer: Blue Shield of California Commercial |
$158.64
|
| Rate for Payer: Blue Shield of California EPN |
$104.47
|
| Rate for Payer: Cash Price |
$118.23
|
| Rate for Payer: Cigna of CA HMO |
$150.47
|
| Rate for Payer: Cigna of CA PPO |
$150.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.98
|
| Rate for Payer: EPIC Health Plan Senior |
$85.98
|
| Rate for Payer: Galaxy Health WC |
$182.72
|
| Rate for Payer: Global Benefits Group Commercial |
$128.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$143.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.59
|
| Rate for Payer: Multiplan Commercial |
$171.97
|
| Rate for Payer: Networks By Design Commercial |
$139.72
|
| Rate for Payer: Prime Health Services Commercial |
$182.72
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
OP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$171.97 |
| Max. Negotiated Rate |
$730.86 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$563.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$472.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$644.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$528.02
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: Cigna of CA HMO |
$601.88
|
| Rate for Payer: Cigna of CA PPO |
$601.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$730.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$730.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$730.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.93
|
| Rate for Payer: EPIC Health Plan Senior |
$343.93
|
| Rate for Payer: Galaxy Health WC |
$730.86
|
| Rate for Payer: Global Benefits Group Commercial |
$515.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$573.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$327.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$532.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$601.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.88
|
| Rate for Payer: Multiplan Commercial |
$687.86
|
| Rate for Payer: Networks By Design Commercial |
$558.89
|
| Rate for Payer: Prime Health Services Commercial |
$730.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$515.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$515.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$429.92
|
| Rate for Payer: United Healthcare All Other HMO |
$429.92
|
| Rate for Payer: United Healthcare HMO Rider |
$429.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$429.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$730.86
|
| Rate for Payer: Vantage Medical Group Senior |
$730.86
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
IP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$171.97 |
| Max. Negotiated Rate |
$730.86 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Blue Shield of California Commercial |
$634.55
|
| Rate for Payer: Blue Shield of California EPN |
$417.88
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: Cigna of CA HMO |
$601.88
|
| Rate for Payer: Cigna of CA PPO |
$601.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.93
|
| Rate for Payer: EPIC Health Plan Senior |
$343.93
|
| Rate for Payer: Galaxy Health WC |
$730.86
|
| Rate for Payer: Global Benefits Group Commercial |
$515.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$573.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$327.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$532.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.36
|
| Rate for Payer: Multiplan Commercial |
$687.86
|
| Rate for Payer: Networks By Design Commercial |
$558.89
|
| Rate for Payer: Prime Health Services Commercial |
$730.86
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
OP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$171.97 |
| Max. Negotiated Rate |
$730.86 |
| Rate for Payer: Cigna of CA PPO |
$601.88
|
| Rate for Payer: Cigna of CA HMO |
$601.88
|
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$563.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$472.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$644.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$528.02
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$730.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$730.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$730.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.93
|
| Rate for Payer: EPIC Health Plan Senior |
$343.93
|
| Rate for Payer: Galaxy Health WC |
$730.86
|
| Rate for Payer: Global Benefits Group Commercial |
$515.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$573.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$327.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$532.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$601.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.88
|
| Rate for Payer: Multiplan Commercial |
$687.86
|
| Rate for Payer: Networks By Design Commercial |
$558.89
|
| Rate for Payer: Prime Health Services Commercial |
$730.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$515.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$515.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$429.92
|
| Rate for Payer: United Healthcare All Other HMO |
$429.92
|
| Rate for Payer: United Healthcare HMO Rider |
$429.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$429.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$730.86
|
| Rate for Payer: Vantage Medical Group Senior |
$730.86
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
IP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$171.97 |
| Max. Negotiated Rate |
$730.86 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Blue Shield of California Commercial |
$634.55
|
| Rate for Payer: Blue Shield of California EPN |
$417.88
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: Cigna of CA HMO |
$601.88
|
| Rate for Payer: Cigna of CA PPO |
$601.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.93
|
| Rate for Payer: EPIC Health Plan Senior |
$343.93
|
| Rate for Payer: Galaxy Health WC |
$730.86
|
| Rate for Payer: Global Benefits Group Commercial |
$515.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$573.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$327.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$532.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.36
|
| Rate for Payer: Multiplan Commercial |
$687.86
|
| Rate for Payer: Networks By Design Commercial |
$558.89
|
| Rate for Payer: Prime Health Services Commercial |
$730.86
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$49.75
|
|
|
Service Code
|
NDC 0023-9177-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$42.29 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.55
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cigna of CA HMO |
$34.83
|
| Rate for Payer: Cigna of CA PPO |
$34.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.90
|
| Rate for Payer: EPIC Health Plan Senior |
$19.90
|
| Rate for Payer: Galaxy Health WC |
$42.29
|
| Rate for Payer: Global Benefits Group Commercial |
$29.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.83
|
| Rate for Payer: Multiplan Commercial |
$39.80
|
| Rate for Payer: Networks By Design Commercial |
$32.34
|
| Rate for Payer: Prime Health Services Commercial |
$42.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.88
|
| Rate for Payer: United Healthcare All Other HMO |
$24.88
|
| Rate for Payer: United Healthcare HMO Rider |
$24.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.29
|
| Rate for Payer: Vantage Medical Group Senior |
$42.29
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.60
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$29.44
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.40
|
| Rate for Payer: United Healthcare All Other HMO |
$18.40
|
| Rate for Payer: United Healthcare HMO Rider |
$18.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.28
|
| Rate for Payer: Vantage Medical Group Senior |
$31.28
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Blue Shield of California Commercial |
$27.16
|
| Rate for Payer: Blue Shield of California EPN |
$17.88
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.83
|
| Rate for Payer: Multiplan Commercial |
$29.44
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$49.75
|
|
|
Service Code
|
NDC 0023-9177-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$42.29 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$36.72
|
| Rate for Payer: Blue Shield of California EPN |
$24.18
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cigna of CA HMO |
$34.83
|
| Rate for Payer: Cigna of CA PPO |
$34.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.90
|
| Rate for Payer: EPIC Health Plan Senior |
$19.90
|
| Rate for Payer: Galaxy Health WC |
$42.29
|
| Rate for Payer: Global Benefits Group Commercial |
$29.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.94
|
| Rate for Payer: Multiplan Commercial |
$39.80
|
| Rate for Payer: Networks By Design Commercial |
$32.34
|
| Rate for Payer: Prime Health Services Commercial |
$42.29
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 70069-231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 70069-231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.90
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$19.97
|
|
|
Service Code
|
NDC 82182-455-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Cigna of CA HMO |
$13.98
|
| Rate for Payer: Cigna of CA PPO |
$13.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.99
|
| Rate for Payer: EPIC Health Plan Senior |
$7.99
|
| Rate for Payer: Galaxy Health WC |
$16.97
|
| Rate for Payer: Global Benefits Group Commercial |
$11.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.98
|
| Rate for Payer: Multiplan Commercial |
$15.98
|
| Rate for Payer: Networks By Design Commercial |
$12.98
|
| Rate for Payer: Prime Health Services Commercial |
$16.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.98
|
| Rate for Payer: United Healthcare All Other HMO |
$9.98
|
| Rate for Payer: United Healthcare HMO Rider |
$9.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Vantage Medical Group Senior |
$16.97
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$30.72
|
|
|
Service Code
|
NDC 0832-1425-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$26.11 |
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Senior |
$12.29
|
| Rate for Payer: Galaxy Health WC |
$26.11
|
| Rate for Payer: Cigna of CA HMO |
$21.50
|
| Rate for Payer: Cigna of CA PPO |
$21.50
|
| Rate for Payer: Adventist Health Commercial |
$6.14
|
| Rate for Payer: Blue Shield of California Commercial |
$22.67
|
| Rate for Payer: Blue Shield of California EPN |
$14.93
|
| Rate for Payer: Cash Price |
$16.89
|
| Rate for Payer: Global Benefits Group Commercial |
$18.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Multiplan Commercial |
$24.58
|
| Rate for Payer: Networks By Design Commercial |
$19.97
|
| Rate for Payer: Prime Health Services Commercial |
$26.11
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$30.72
|
|
|
Service Code
|
NDC 0832-1425-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$26.11 |
| Rate for Payer: Adventist Health Commercial |
$6.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$20.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.87
|
| Rate for Payer: Cash Price |
$16.89
|
| Rate for Payer: Cigna of CA HMO |
$21.50
|
| Rate for Payer: Cigna of CA PPO |
$21.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Senior |
$12.29
|
| Rate for Payer: Galaxy Health WC |
$26.11
|
| Rate for Payer: Global Benefits Group Commercial |
$18.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$24.58
|
| Rate for Payer: Networks By Design Commercial |
$19.97
|
| Rate for Payer: Prime Health Services Commercial |
$26.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.36
|
| Rate for Payer: United Healthcare All Other HMO |
$15.36
|
| Rate for Payer: United Healthcare HMO Rider |
$15.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.11
|
| Rate for Payer: Vantage Medical Group Senior |
$26.11
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$19.97
|
|
|
Service Code
|
NDC 82182-455-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Blue Shield of California Commercial |
$14.74
|
| Rate for Payer: Blue Shield of California EPN |
$9.71
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Cigna of CA HMO |
$13.98
|
| Rate for Payer: Cigna of CA PPO |
$13.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.99
|
| Rate for Payer: EPIC Health Plan Senior |
$7.99
|
| Rate for Payer: Galaxy Health WC |
$16.97
|
| Rate for Payer: Global Benefits Group Commercial |
$11.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.79
|
| Rate for Payer: Multiplan Commercial |
$15.98
|
| Rate for Payer: Networks By Design Commercial |
$12.98
|
| Rate for Payer: Prime Health Services Commercial |
$16.97
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$41.64 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.08
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Cigna of CA HMO |
$34.29
|
| Rate for Payer: Cigna of CA PPO |
$34.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$41.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$41.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.60
|
| Rate for Payer: EPIC Health Plan Senior |
$19.60
|
| Rate for Payer: Galaxy Health WC |
$41.64
|
| Rate for Payer: Global Benefits Group Commercial |
$29.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.29
|
| Rate for Payer: Multiplan Commercial |
$39.19
|
| Rate for Payer: Networks By Design Commercial |
$31.84
|
| Rate for Payer: Prime Health Services Commercial |
$41.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.50
|
| Rate for Payer: United Healthcare All Other HMO |
$24.50
|
| Rate for Payer: United Healthcare HMO Rider |
$24.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.64
|
| Rate for Payer: Vantage Medical Group Senior |
$41.64
|
|
