|
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 |
$8.89 |
| Max. Negotiated Rate |
$31.48 |
| 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 |
$20.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.06
|
| Rate for Payer: Blue Distinction Transplant |
$22.22
|
| Rate for Payer: Blue Shield of California Commercial |
$27.29
|
| Rate for Payer: Blue Shield of California EPN |
$21.63
|
| Rate for Payer: Cash Price |
$16.66
|
| 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 Media |
$31.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.81
|
| Rate for Payer: Galaxy Health WC |
$31.48
|
| Rate for Payer: Global Benefits Group Commercial |
$22.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$27.77
|
| 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: 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
|
| 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
|
|
|
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 |
$8.43 |
| Max. Negotiated Rate |
$29.87 |
| 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 |
$19.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.94
|
| Rate for Payer: Blue Distinction Transplant |
$21.08
|
| Rate for Payer: Blue Shield of California Commercial |
$25.90
|
| Rate for Payer: Blue Shield of California EPN |
$20.52
|
| Rate for Payer: Cash Price |
$15.81
|
| 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 Media |
$29.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.06
|
| Rate for Payer: Galaxy Health WC |
$29.87
|
| Rate for Payer: Global Benefits Group Commercial |
$21.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$26.36
|
| 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: 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
|
| 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
|
|
|
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 |
$6.60 |
| Max. Negotiated Rate |
$23.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.38
|
| Rate for Payer: Blue Distinction Transplant |
$16.50
|
| Rate for Payer: Blue Shield of California Commercial |
$20.27
|
| Rate for Payer: Blue Shield of California EPN |
$16.06
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.38
|
| Rate for Payer: Dignity Health Media |
$23.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.75
|
| Rate for Payer: United Healthcare All Other HMO |
$13.75
|
| Rate for Payer: United Healthcare HMO Rider |
$13.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.38
|
| Rate for Payer: Vantage Medical Group Senior |
$23.38
|
|
|
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 |
$6.60 |
| Max. Negotiated Rate |
$23.38 |
| Rate for Payer: Blue Shield of California Commercial |
$19.58
|
| Rate for Payer: Blue Shield of California EPN |
$14.08
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
|
|
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 |
$1.32 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: Blue Distinction Transplant |
$3.30
|
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California EPN |
$3.21
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.68
|
| Rate for Payer: Dignity Health Media |
$4.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.75
|
| Rate for Payer: United Healthcare HMO Rider |
$2.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4.68
|
|
|
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 |
$1.32 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.82
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.68
|
|
|
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 |
$3.40 |
| Max. Negotiated Rate |
$12.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.43
|
| Rate for Payer: Blue Distinction Transplant |
$8.49
|
| Rate for Payer: Blue Shield of California Commercial |
$10.43
|
| Rate for Payer: Blue Shield of California EPN |
$8.26
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Cigna of CA HMO |
$9.90
|
| Rate for Payer: Cigna of CA PPO |
$9.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: Dignity Health Media |
$12.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.66
|
| Rate for Payer: Galaxy Health WC |
$12.03
|
| Rate for Payer: Global Benefits Group Commercial |
$8.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$11.32
|
| Rate for Payer: Networks By Design Commercial |
$7.08
|
| Rate for Payer: Prime Health Services Commercial |
$12.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.08
|
| Rate for Payer: United Healthcare All Other HMO |
$7.08
|
| Rate for Payer: United Healthcare HMO Rider |
$7.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.03
|
| Rate for Payer: Vantage Medical Group Senior |
$12.03
|
|
|
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 |
$3.40 |
| Max. Negotiated Rate |
$12.03 |
| Rate for Payer: Blue Shield of California Commercial |
$10.07
|
| Rate for Payer: Blue Shield of California EPN |
$7.24
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Cigna of CA HMO |
$9.90
|
| Rate for Payer: Cigna of CA PPO |
$9.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.66
|
| Rate for Payer: Galaxy Health WC |
$12.03
|
| Rate for Payer: Global Benefits Group Commercial |
$8.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$11.32
|
| Rate for Payer: Networks By Design Commercial |
$7.08
|
| Rate for Payer: Prime Health Services Commercial |
$12.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.34
|
| Rate for Payer: United Healthcare All Other HMO |
$5.22
|
| Rate for Payer: United Healthcare HMO Rider |
$5.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.67
|
|
|
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 |
$6.60 |
| Max. Negotiated Rate |
$23.38 |
| Rate for Payer: Blue Shield of California Commercial |
$19.58
|
| Rate for Payer: Blue Shield of California EPN |
$14.08
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
|
|
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 |
$6.60 |
| Max. Negotiated Rate |
$23.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.38
|
| Rate for Payer: Blue Distinction Transplant |
$16.50
|
| Rate for Payer: Blue Shield of California Commercial |
$20.27
|
| Rate for Payer: Blue Shield of California EPN |
$16.06
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.38
|
| Rate for Payer: Dignity Health Media |
$23.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.75
|
| Rate for Payer: United Healthcare All Other HMO |
$13.75
|
| Rate for Payer: United Healthcare HMO Rider |
$13.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.38
|
| Rate for Payer: Vantage Medical Group Senior |
$23.38
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
OP
|
$125.69
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$106.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$82.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$82.45
|
| 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 Commercial/Exchange |
$106.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.13
|
| Rate for Payer: Blue Distinction Transplant |
$60.34
|
| Rate for Payer: Blue Distinction Transplant |
$75.41
|
| Rate for Payer: Blue Distinction Transplant |
$75.42
|
| Rate for Payer: Blue Shield of California Commercial |
$92.63
|
| Rate for Payer: Blue Shield of California Commercial |
$74.11
|
| Rate for Payer: Blue Shield of California Commercial |
$92.64
|
| Rate for Payer: Blue Shield of California EPN |
$73.41
|
| Rate for Payer: Blue Shield of California EPN |
$58.73
|
| Rate for Payer: Blue Shield of California EPN |
$73.40
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cigna of CA HMO |
$70.39
|
| Rate for Payer: Cigna of CA HMO |
$87.99
|
| Rate for Payer: Cigna of CA HMO |
$87.98
|
| Rate for Payer: Cigna of CA PPO |
$70.39
|
| Rate for Payer: Cigna of CA PPO |
$87.98
|
| Rate for Payer: Cigna of CA PPO |
$87.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.84
|
| Rate for Payer: Dignity Health Media |
$106.84
|
| Rate for Payer: Dignity Health Media |
$85.48
|
| Rate for Payer: Dignity Health Media |
$106.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Galaxy Health WC |
$85.48
|
| Rate for Payer: Global Benefits Group Commercial |
$75.42
|
| Rate for Payer: Global Benefits Group Commercial |
$60.34
|
| Rate for Payer: Global Benefits Group Commercial |
$75.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$75.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$94.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$94.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.17
|
| Rate for Payer: Multiplan Commercial |
$100.56
|
| Rate for Payer: Multiplan Commercial |
$80.45
|
| Rate for Payer: Multiplan Commercial |
$100.55
|
| Rate for Payer: Networks By Design Commercial |
$62.84
|
| Rate for Payer: Networks By Design Commercial |
$50.28
|
| Rate for Payer: Networks By Design Commercial |
$62.85
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$85.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$75.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$75.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$75.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$75.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$62.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$62.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$50.28
|
| Rate for Payer: United Healthcare All Other HMO |
$50.28
|
| Rate for Payer: United Healthcare All Other HMO |
$62.85
|
| Rate for Payer: United Healthcare All Other HMO |
$62.84
|
| Rate for Payer: United Healthcare HMO Rider |
$50.28
|
| Rate for Payer: United Healthcare HMO Rider |
$62.85
|
| Rate for Payer: United Healthcare HMO Rider |
$62.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$50.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$85.48
|
| Rate for Payer: Vantage Medical Group Senior |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$106.84
|
|
|
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 |
$24.13 |
| Max. Negotiated Rate |
$85.48 |
| Rate for Payer: Blue Shield of California Commercial |
$71.60
|
| Rate for Payer: Blue Shield of California Commercial |
$89.49
|
| Rate for Payer: Blue Shield of California Commercial |
$89.50
|
| Rate for Payer: Blue Shield of California EPN |
$64.35
|
| Rate for Payer: Blue Shield of California EPN |
$64.36
|
| Rate for Payer: Blue Shield of California EPN |
$51.49
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cigna of CA HMO |
$87.99
|
| Rate for Payer: Cigna of CA HMO |
$87.98
|
| Rate for Payer: Cigna of CA HMO |
$70.39
|
| Rate for Payer: Cigna of CA PPO |
$70.39
|
| Rate for Payer: Cigna of CA PPO |
$87.98
|
| Rate for Payer: Cigna of CA PPO |
$87.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Galaxy Health WC |
$85.48
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Global Benefits Group Commercial |
$75.42
|
| Rate for Payer: Global Benefits Group Commercial |
$60.34
|
| Rate for Payer: Global Benefits Group Commercial |
$75.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.17
|
| Rate for Payer: Multiplan Commercial |
$80.45
|
| Rate for Payer: Multiplan Commercial |
$100.55
|
| Rate for Payer: Multiplan Commercial |
$100.56
|
| Rate for Payer: Networks By Design Commercial |
$62.84
|
| Rate for Payer: Networks By Design Commercial |
$50.28
|
| Rate for Payer: Networks By Design Commercial |
$62.85
|
| Rate for Payer: Prime Health Services Commercial |
$85.48
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$37.97
|
| Rate for Payer: United Healthcare All Other HMO |
$46.35
|
| Rate for Payer: United Healthcare All Other HMO |
$37.09
|
| Rate for Payer: United Healthcare All Other HMO |
$46.36
|
| Rate for Payer: United Healthcare HMO Rider |
$45.35
|
| Rate for Payer: United Healthcare HMO Rider |
$36.28
|
| Rate for Payer: United Healthcare HMO Rider |
$45.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.48
|
|
|
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 |
$0.95 |
| Max. Negotiated Rate |
$3.37 |
| 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 |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.37
|
| Rate for Payer: Blue Distinction Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.32
|
| Rate for Payer: Cash Price |
$1.79
|
| 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 Media |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.98
|
| 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: 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
|
| 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 |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| 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 |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.37 |
| 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 |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.37
|
| Rate for Payer: Blue Distinction Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.32
|
| Rate for Payer: Cash Price |
$1.79
|
| 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 Media |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.98
|
| 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: 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
|
| 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 |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| 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
|
IP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Blue Shield of California Commercial |
$4.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$2.71
|
| 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: 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: 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
|
OP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.12 |
| 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 |
$3.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.59
|
| Rate for Payer: Blue Distinction Transplant |
$3.61
|
| Rate for Payer: Blue Shield of California Commercial |
$4.44
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.71
|
| 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 Media |
$5.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.52
|
| 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: 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
|
| 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
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$1.79
|
| 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: 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: 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
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$1.79
|
| 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: 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: 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
|
|
|
BROMPHENIRAMINE-PHENYLEPHRINE 1 MG-2.5 MG/5 ML ORAL SOLUTION [77434]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 49348-777-34
|
| Hospital Charge Code |
NDG77434
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
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
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$10,385.38
|
|
|
Service Code
|
APR-DRG 1383
|
| Min. Negotiated Rate |
$7,966.68 |
| Max. Negotiated Rate |
$10,385.38 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,966.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,385.38
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$4,577.31
|
|
|
Service Code
|
APR-DRG 1381
|
| Min. Negotiated Rate |
$3,511.28 |
| Max. Negotiated Rate |
$4,577.31 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,511.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,577.31
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$22,077.81
|
|
|
Service Code
|
APR-DRG 1384
|
| Min. Negotiated Rate |
$16,936.00 |
| Max. Negotiated Rate |
$22,077.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,936.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,077.81
|
|
|
BRONCHIOLITIS AND RSV PNEUMONIA
|
Facility
|
IP
|
$6,556.48
|
|
|
Service Code
|
APR-DRG 1382
|
| Min. Negotiated Rate |
$5,029.51 |
| Max. Negotiated Rate |
$6,556.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,029.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,556.48
|
|
|
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 31622
|
| Min. Negotiated Rate |
$313.37 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,120.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Dignity Health Media |
$2,120.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,332.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,862.84
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,120.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,120.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,477.82
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,477.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,435.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,435.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,120.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$313.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,120.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,671.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,841.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,180.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,332.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2,120.62
|
|
