|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
OP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
1740307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.83 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: BCBS Transplant Transplant |
$22.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.93
|
| Rate for Payer: Blue Shield of California Commercial |
$27.12
|
| Rate for Payer: Blue Shield of California EPN |
$21.49
|
| Rate for Payer: Cash Price |
$16.56
|
| 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 Media |
$31.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27.60
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$22.08
|
| 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
|
$49.75
|
|
|
Service Code
|
NDC 0023-9177-05
|
| Hospital Charge Code |
1740307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$42.29 |
| Rate for Payer: Blue Shield of California Commercial |
$35.42
|
| Rate for Payer: Blue Shield of California EPN |
$25.47
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Cigna of CA HMO |
$34.82
|
| Rate for Payer: Cigna of CA PPO |
$34.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
$2.40
|
|
|
Service Code
|
NDC 61314-143-05
|
| Hospital Charge Code |
NDG17881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
OP
|
$3.53
|
|
|
Service Code
|
NDC 17478-715-10
|
| Hospital Charge Code |
NDG17881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.10
|
| Rate for Payer: BCBS Transplant Transplant |
$2.12
|
| Rate for Payer: Blue Shield of California Commercial |
$2.60
|
| Rate for Payer: Blue Shield of California EPN |
$2.06
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cigna of CA HMO |
$2.47
|
| Rate for Payer: Cigna of CA PPO |
$2.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.00
|
| Rate for Payer: Dignity Health Media |
$3.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.41
|
| Rate for Payer: Galaxy Health WC |
$3.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.82
|
| Rate for Payer: Networks By Design Commercial |
$2.29
|
| Rate for Payer: Prime Health Services Commercial |
$3.00
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.76
|
| Rate for Payer: United Healthcare All Other HMO |
$1.76
|
| Rate for Payer: United Healthcare HMO Rider |
$1.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3.00
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
NDC 70069-232-01
|
| Hospital Charge Code |
NDG17881B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: BCBS Transplant Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
OP
|
$3.48
|
|
|
Service Code
|
NDC 24208-411-05
|
| Hospital Charge Code |
NDG17881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: BCBS Transplant Transplant |
$2.09
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cigna of CA HMO |
$2.44
|
| Rate for Payer: Cigna of CA PPO |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.96
|
| Rate for Payer: Dignity Health Media |
$2.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.39
|
| Rate for Payer: Galaxy Health WC |
$2.96
|
| Rate for Payer: Global Benefits Group Commercial |
$2.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.78
|
| Rate for Payer: Networks By Design Commercial |
$2.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.96
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1.74
|
| Rate for Payer: United Healthcare HMO Rider |
$1.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.96
|
| Rate for Payer: Vantage Medical Group Senior |
$2.96
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
IP
|
$3.53
|
|
|
Service Code
|
NDC 17478-715-10
|
| Hospital Charge Code |
NDG17881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: EPIC Health Plan Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cigna of CA HMO |
$2.47
|
| Rate for Payer: Cigna of CA PPO |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$3.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.82
|
| Rate for Payer: Networks By Design Commercial |
$2.29
|
| Rate for Payer: Prime Health Services Commercial |
$3.00
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
IP
|
$3.48
|
|
|
Service Code
|
NDC 24208-411-05
|
| Hospital Charge Code |
NDG17881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cigna of CA HMO |
$2.44
|
| Rate for Payer: Cigna of CA PPO |
$2.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Galaxy Health WC |
$2.96
|
| Rate for Payer: Global Benefits Group Commercial |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.78
|
| Rate for Payer: Networks By Design Commercial |
$2.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.96
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
OP
|
$2.40
|
|
|
Service Code
|
NDC 61314-143-05
|
| Hospital Charge Code |
NDG17881
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.43
|
| Rate for Payer: BCBS Transplant Transplant |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Media |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
IP
|
$0.80
|
|
|
Service Code
|
NDC 70069-232-01
|
| Hospital Charge Code |
NDG17881B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
IP
|
$42.55
|
|
|
Service Code
|
NDC 60505-0589-1
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$36.17 |
| Rate for Payer: Blue Shield of California Commercial |
$30.30
|
| Rate for Payer: Blue Shield of California EPN |
$21.79
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cigna of CA HMO |
$29.78
|
| Rate for Payer: Cigna of CA PPO |
$29.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.02
|
| Rate for Payer: Galaxy Health WC |
$36.17
|
| Rate for Payer: Global Benefits Group Commercial |
$25.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.21
|
| Rate for Payer: Multiplan Commercial |
$34.04
|
| Rate for Payer: Networks By Design Commercial |
$27.66
|
| Rate for Payer: Prime Health Services Commercial |
$36.17
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
OP
|
$42.55
|
|
|
Service Code
|
NDC 60505-0589-1
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$36.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$36.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.35
|
| Rate for Payer: BCBS Transplant Transplant |
$25.53
|
| Rate for Payer: Blue Shield of California Commercial |
$31.36
|
| Rate for Payer: Blue Shield of California EPN |
$24.85
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cigna of CA HMO |
$29.78
|
| Rate for Payer: Cigna of CA PPO |
$29.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.17
|
| Rate for Payer: Dignity Health Media |
$36.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$17.02
|
| Rate for Payer: Galaxy Health WC |
$36.17
|
| Rate for Payer: Global Benefits Group Commercial |
$25.53
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$31.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.21
|
| Rate for Payer: Multiplan Commercial |
$34.04
|
| Rate for Payer: Networks By Design Commercial |
$27.66
|
| Rate for Payer: Prime Health Services Commercial |
$36.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$25.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.28
|
| Rate for Payer: United Healthcare All Other HMO |
$21.28
|
| Rate for Payer: United Healthcare HMO Rider |
$21.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.17
|
| Rate for Payer: Vantage Medical Group Senior |
$36.17
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$41.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.19
|
| Rate for Payer: BCBS Transplant Transplant |
$29.39
|
| Rate for Payer: Blue Shield of California Commercial |
$36.11
|
| Rate for Payer: Blue Shield of California EPN |
$28.61
|
| Rate for Payer: Cash Price |
$22.05
|
| 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 Media |
$41.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.60
|
| Rate for Payer: Galaxy Health WC |
$41.64
|
| Rate for Payer: Global Benefits Group Commercial |
$29.39
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$36.74
|
| 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: LLUH Dept of Risk Management WC |
$11.76
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$29.39
|
| 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
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
IP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$41.64 |
| Rate for Payer: Blue Shield of California Commercial |
$34.88
|
| Rate for Payer: Blue Shield of California EPN |
$25.08
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: Cigna of CA HMO |
$34.29
|
| Rate for Payer: Cigna of CA PPO |
$34.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$11.76
|
| 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
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
IP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$24.32 |
| Rate for Payer: Blue Shield of California Commercial |
$20.37
|
| Rate for Payer: Blue Shield of California EPN |
$14.65
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.44
|
| Rate for Payer: Galaxy Health WC |
$24.32
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$22.89
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.32
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
OP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$24.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.05
|
| Rate for Payer: BCBS Transplant Transplant |
$17.17
|
| Rate for Payer: Blue Shield of California Commercial |
$21.09
|
| Rate for Payer: Blue Shield of California EPN |
$16.71
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.32
|
| Rate for Payer: Dignity Health Media |
$24.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.44
|
| Rate for Payer: Galaxy Health WC |
$24.32
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$21.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$22.89
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.32
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.30
|
| Rate for Payer: United Healthcare All Other HMO |
$14.30
|
| Rate for Payer: United Healthcare HMO Rider |
$14.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.32
|
| Rate for Payer: Vantage Medical Group Senior |
$24.32
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$31.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.06
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$22.22
|
| 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
IP
|
$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: Blue Shield of California Commercial |
$25.02
|
| Rate for Payer: Blue Shield of California EPN |
$17.99
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$29.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.94
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$21.08
|
| 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 |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$31.48 |
| Rate for Payer: Blue Shield of California Commercial |
$26.37
|
| Rate for Payer: Blue Shield of California EPN |
$18.96
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.38
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$16.50
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$3.30
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.43
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant 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
|
|
