|
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
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$29.87 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$23.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.58
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cigna of CA HMO |
$24.60
|
| Rate for Payer: Cigna of CA PPO |
$24.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: EPIC Health Plan Senior |
$14.06
|
| Rate for Payer: Galaxy Health WC |
$29.87
|
| Rate for Payer: Global Benefits Group Commercial |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.60
|
| Rate for Payer: Multiplan Commercial |
$28.11
|
| Rate for Payer: Networks By Design Commercial |
$22.84
|
| Rate for Payer: Prime Health Services Commercial |
$29.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.57
|
| Rate for Payer: United Healthcare All Other HMO |
$17.57
|
| Rate for Payer: United Healthcare HMO Rider |
$17.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.87
|
| Rate for Payer: Vantage Medical Group Senior |
$29.87
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
IP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$31.48 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California Commercial |
$27.33
|
| Rate for Payer: Blue Shield of California EPN |
$18.00
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Cigna of CA HMO |
$25.92
|
| Rate for Payer: Cigna of CA PPO |
$25.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: EPIC Health Plan Senior |
$14.81
|
| Rate for Payer: Galaxy Health WC |
$31.48
|
| Rate for Payer: Global Benefits Group Commercial |
$22.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.89
|
| Rate for Payer: Multiplan Commercial |
$29.62
|
| Rate for Payer: Networks By Design Commercial |
$24.07
|
| Rate for Payer: Prime Health Services Commercial |
$31.48
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
IP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$29.87 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Blue Shield of California Commercial |
$25.93
|
| Rate for Payer: Blue Shield of California EPN |
$17.08
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cigna of CA HMO |
$24.60
|
| Rate for Payer: Cigna of CA PPO |
$24.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: EPIC Health Plan Senior |
$14.06
|
| Rate for Payer: Galaxy Health WC |
$29.87
|
| Rate for Payer: Global Benefits Group Commercial |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Multiplan Commercial |
$28.11
|
| Rate for Payer: Networks By Design Commercial |
$22.84
|
| Rate for Payer: Prime Health Services Commercial |
$29.87
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$31.48 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.74
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Cigna of CA HMO |
$25.92
|
| Rate for Payer: Cigna of CA PPO |
$25.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: EPIC Health Plan Senior |
$14.81
|
| Rate for Payer: Galaxy Health WC |
$31.48
|
| Rate for Payer: Global Benefits Group Commercial |
$22.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.92
|
| Rate for Payer: Multiplan Commercial |
$29.62
|
| Rate for Payer: Networks By Design Commercial |
$24.07
|
| Rate for Payer: Prime Health Services Commercial |
$31.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.52
|
| Rate for Payer: United Healthcare All Other HMO |
$18.52
|
| Rate for Payer: United Healthcare HMO Rider |
$18.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.48
|
| Rate for Payer: Vantage Medical Group Senior |
$31.48
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Multiplan Commercial |
$23.57
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.09
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$20.62
|
| Rate for Payer: Cigna of CA PPO |
$20.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: EPIC Health Plan Senior |
$11.78
|
| Rate for Payer: Galaxy Health WC |
$25.04
|
| Rate for Payer: Global Benefits Group Commercial |
$17.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.62
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.73
|
| Rate for Payer: United Healthcare All Other HMO |
$14.73
|
| Rate for Payer: United Healthcare HMO Rider |
$14.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.04
|
| Rate for Payer: Vantage Medical Group Senior |
$25.04
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Blue Shield of California Commercial |
$21.74
|
| Rate for Payer: Blue Shield of California EPN |
$14.32
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$20.62
|
| Rate for Payer: Cigna of CA PPO |
$20.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: EPIC Health Plan Senior |
$11.78
|
| Rate for Payer: Galaxy Health WC |
$25.04
|
| Rate for Payer: Global Benefits Group Commercial |
$17.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.07
|
| Rate for Payer: Multiplan Commercial |
$23.57
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
IP
|
$5.89
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$5.01 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$4.35
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO |
$4.12
|
| Rate for Payer: Cigna of CA PPO |
$4.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Senior |
$2.36
|
| Rate for Payer: Galaxy Health WC |
$5.01
|
| Rate for Payer: Global Benefits Group Commercial |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$4.71
|
| Rate for Payer: Networks By Design Commercial |
$3.83
|
| Rate for Payer: Prime Health Services Commercial |
$5.01
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
OP
|
$5.89
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$5.01 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.62
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO |
$4.12
|
| Rate for Payer: Cigna of CA PPO |
$4.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Senior |
$2.36
|
| Rate for Payer: Galaxy Health WC |
$5.01
|
| Rate for Payer: Global Benefits Group Commercial |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.12
|
| Rate for Payer: Multiplan Commercial |
$4.71
|
| Rate for Payer: Networks By Design Commercial |
$3.83
|
| Rate for Payer: Prime Health Services Commercial |
$5.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.94
|
| Rate for Payer: United Healthcare All Other HMO |
$2.94
|
| Rate for Payer: United Healthcare HMO Rider |
$2.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.01
|
| Rate for Payer: Vantage Medical Group Senior |
$5.01
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
OP
|
$15.15
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.30
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO |
$10.61
|
| Rate for Payer: Cigna of CA PPO |
$10.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: EPIC Health Plan Senior |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$12.88
|
| Rate for Payer: Global Benefits Group Commercial |
$9.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.61
|
| Rate for Payer: Multiplan Commercial |
$12.12
|
| Rate for Payer: Networks By Design Commercial |
$7.58
|
| Rate for Payer: Prime Health Services Commercial |
$12.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.69
|
| Rate for Payer: United Healthcare All Other HMO |
$5.53
|
| Rate for Payer: United Healthcare HMO Rider |
$5.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.88
|
| Rate for Payer: Vantage Medical Group Senior |
$12.88
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
IP
|
$15.15
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$11.18
|
| Rate for Payer: Blue Shield of California EPN |
$7.36
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO |
$10.61
|
| Rate for Payer: Cigna of CA PPO |
$10.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: EPIC Health Plan Senior |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$12.88
|
| Rate for Payer: Global Benefits Group Commercial |
$9.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.64
|
| Rate for Payer: Multiplan Commercial |
$12.12
|
| Rate for Payer: Networks By Design Commercial |
$7.58
|
| Rate for Payer: Prime Health Services Commercial |
$12.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.69
|
| Rate for Payer: United Healthcare All Other HMO |
$5.53
|
| Rate for Payer: United Healthcare HMO Rider |
$5.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.96
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.09
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$20.62
|
| Rate for Payer: Cigna of CA PPO |
$20.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: EPIC Health Plan Senior |
$11.78
|
| Rate for Payer: Galaxy Health WC |
$25.04
|
| Rate for Payer: Global Benefits Group Commercial |
$17.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$23.57
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.73
|
| Rate for Payer: United Healthcare All Other HMO |
$14.73
|
| Rate for Payer: United Healthcare HMO Rider |
$14.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.04
|
| Rate for Payer: Vantage Medical Group Senior |
$25.04
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Blue Shield of California Commercial |
$21.74
|
| Rate for Payer: Blue Shield of California EPN |
$14.32
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$20.62
|
| Rate for Payer: Cigna of CA PPO |
$20.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: EPIC Health Plan Senior |
$11.78
|
| Rate for Payer: Galaxy Health WC |
$25.04
|
| Rate for Payer: Global Benefits Group Commercial |
$17.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.07
|
| Rate for Payer: Multiplan Commercial |
$23.57
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.09
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$20.62
|
| Rate for Payer: Cigna of CA PPO |
$20.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: EPIC Health Plan Senior |
$11.78
|
| Rate for Payer: Galaxy Health WC |
$25.04
|
| Rate for Payer: Global Benefits Group Commercial |
$17.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$23.57
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.73
|
| Rate for Payer: United Healthcare All Other HMO |
$14.73
|
| Rate for Payer: United Healthcare HMO Rider |
$14.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.04
|
| Rate for Payer: Vantage Medical Group Senior |
$25.04
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Blue Shield of California Commercial |
$21.74
|
| Rate for Payer: Blue Shield of California EPN |
$14.32
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$20.62
|
| Rate for Payer: Cigna of CA PPO |
$20.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: EPIC Health Plan Senior |
$11.78
|
| Rate for Payer: Galaxy Health WC |
$25.04
|
| Rate for Payer: Global Benefits Group Commercial |
$17.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.07
|
| Rate for Payer: Multiplan Commercial |
$23.57
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
OP
|
$100.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.11 |
| Max. Negotiated Rate |
$85.48 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$65.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.75
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO |
$70.39
|
| Rate for Payer: Cigna of CA PPO |
$70.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Senior |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$85.48
|
| Rate for Payer: Global Benefits Group Commercial |
$60.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$62.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.39
|
| Rate for Payer: Multiplan Commercial |
$80.45
|
| Rate for Payer: Networks By Design Commercial |
$50.28
|
| Rate for Payer: Prime Health Services Commercial |
$85.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$37.74
|
| Rate for Payer: United Healthcare All Other HMO |
$36.73
|
| Rate for Payer: United Healthcare HMO Rider |
$35.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$32.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.48
|
| Rate for Payer: Vantage Medical Group Senior |
$85.48
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
IP
|
$100.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.11 |
| Max. Negotiated Rate |
$85.48 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Blue Shield of California Commercial |
$74.21
|
| Rate for Payer: Blue Shield of California EPN |
$48.87
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO |
$70.39
|
| Rate for Payer: Cigna of CA PPO |
$70.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Senior |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$85.48
|
| Rate for Payer: Global Benefits Group Commercial |
$60.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$62.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.13
|
| Rate for Payer: Multiplan Commercial |
$80.45
|
| Rate for Payer: Networks By Design Commercial |
$50.28
|
| Rate for Payer: Prime Health Services Commercial |
$85.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$37.74
|
| Rate for Payer: United Healthcare All Other HMO |
$36.73
|
| Rate for Payer: United Healthcare HMO Rider |
$35.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$32.93
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.44
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.70
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.01
|
| Rate for Payer: United Healthcare All Other HMO |
$3.01
|
| Rate for Payer: United Healthcare HMO Rider |
$3.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Vantage Medical Group Senior |
$5.12
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.44
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.44
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Senior |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$3.18
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.99
|
| Rate for Payer: United Healthcare All Other HMO |
$1.99
|
| Rate for Payer: United Healthcare HMO Rider |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 0093-6815-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna of CA HMO |
$3.16
|
| Rate for Payer: Cigna of CA PPO |
$3.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: EPIC Health Plan Senior |
$1.81
|
| Rate for Payer: Galaxy Health WC |
$3.84
|
| Rate for Payer: Global Benefits Group Commercial |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.62
|
| Rate for Payer: Networks By Design Commercial |
$2.94
|
| Rate for Payer: Prime Health Services Commercial |
$3.84
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
OP
|
$20.40
|
|
|
Service Code
|
NDC 0487-9601-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$17.34 |
| Rate for Payer: Adventist Health Commercial |
$4.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.53
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Cigna of CA HMO |
$14.28
|
| Rate for Payer: Cigna of CA PPO |
$14.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.16
|
| Rate for Payer: EPIC Health Plan Senior |
$8.16
|
| Rate for Payer: Galaxy Health WC |
$17.34
|
| Rate for Payer: Global Benefits Group Commercial |
$12.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.28
|
| Rate for Payer: Multiplan Commercial |
$16.32
|
| Rate for Payer: Networks By Design Commercial |
$13.26
|
| Rate for Payer: Prime Health Services Commercial |
$17.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.20
|
| Rate for Payer: United Healthcare All Other HMO |
$10.20
|
| Rate for Payer: United Healthcare HMO Rider |
$10.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.34
|
| Rate for Payer: Vantage Medical Group Senior |
$17.34
|
|
