|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Blue Shield of California Commercial |
$28.45
|
| Rate for Payer: Blue Shield of California EPN |
$18.55
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Central Health Plan Commercial |
$29.44
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$27.60
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.61
|
| Rate for Payer: Blue Shield of California Commercial |
$22.48
|
| Rate for Payer: Blue Shield of California EPN |
$14.68
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Central Health Plan Commercial |
$29.44
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.12
|
| Rate for Payer: InnovAge PACE Commercial |
$18.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$27.60
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
| Rate for Payer: Riverside University Health System MISP |
$14.72
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$44.77 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$38.46
|
| Rate for Payer: Blue Shield of California EPN |
$25.07
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Central Health Plan Commercial |
$39.80
|
| Rate for Payer: Cigna of CA HMO |
$34.83
|
| Rate for Payer: Cigna of CA PPO |
$34.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.90
|
| Rate for Payer: EPIC Health Plan Senior |
$19.90
|
| Rate for Payer: Galaxy Health WC |
$42.29
|
| Rate for Payer: Global Benefits Group Commercial |
$29.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Multiplan Commercial |
$37.31
|
| Rate for Payer: Networks By Design Commercial |
$32.34
|
| Rate for Payer: Prime Health Services Commercial |
$42.29
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$49.75
|
|
|
Service Code
|
NDC 0023-9177-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$44.77 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.22
|
| Rate for Payer: Blue Shield of California Commercial |
$30.40
|
| Rate for Payer: Blue Shield of California EPN |
$19.85
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Central Health Plan Commercial |
$39.80
|
| Rate for Payer: Cigna of CA HMO |
$34.83
|
| Rate for Payer: Cigna of CA PPO |
$34.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.90
|
| Rate for Payer: EPIC Health Plan Senior |
$19.90
|
| Rate for Payer: Galaxy Health WC |
$42.29
|
| Rate for Payer: Global Benefits Group Commercial |
$29.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.77
|
| Rate for Payer: InnovAge PACE Commercial |
$24.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.83
|
| Rate for Payer: Multiplan Commercial |
$37.31
|
| Rate for Payer: Networks By Design Commercial |
$32.34
|
| Rate for Payer: Prime Health Services Commercial |
$42.29
|
| Rate for Payer: Riverside University Health System MISP |
$19.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.88
|
| Rate for Payer: United Healthcare All Other HMO |
$24.88
|
| Rate for Payer: United Healthcare HMO Rider |
$24.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.29
|
| Rate for Payer: Vantage Medical Group Senior |
$42.29
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 70069-231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 70069-231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: InnovAge PACE Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Riverside University Health System MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$30.72
|
|
|
Service Code
|
NDC 0832-1425-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: Adventist Health Commercial |
$6.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.04
|
| Rate for Payer: Blue Shield of California Commercial |
$18.77
|
| Rate for Payer: Blue Shield of California EPN |
$12.26
|
| Rate for Payer: Cash Price |
$16.89
|
| Rate for Payer: Central Health Plan Commercial |
$24.58
|
| Rate for Payer: Cigna of CA HMO |
$21.50
|
| Rate for Payer: Cigna of CA PPO |
$21.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Senior |
$12.29
|
| Rate for Payer: Galaxy Health WC |
$26.11
|
| Rate for Payer: Global Benefits Group Commercial |
$18.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.65
|
| Rate for Payer: InnovAge PACE Commercial |
$15.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
| Rate for Payer: Networks By Design Commercial |
$19.97
|
| Rate for Payer: Prime Health Services Commercial |
$26.11
|
| Rate for Payer: Riverside University Health System MISP |
$12.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.36
|
| Rate for Payer: United Healthcare All Other HMO |
$15.36
|
| Rate for Payer: United Healthcare HMO Rider |
$15.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.11
|
| Rate for Payer: Vantage Medical Group Senior |
$26.11
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$44.09 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Blue Shield of California Commercial |
$37.87
|
| Rate for Payer: Blue Shield of California EPN |
$24.69
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Central Health Plan Commercial |
$39.19
|
| 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: EPIC Health Plan Senior |
$19.60
|
| Rate for Payer: Galaxy Health WC |
$41.64
|
| Rate for Payer: Global Benefits Group Commercial |
$29.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.80
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Networks By Design Commercial |
$31.84
|
| Rate for Payer: Prime Health Services Commercial |
$41.64
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$44.09 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$29.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.74
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$23.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.77
|
| Rate for Payer: Blue Shield of California Commercial |
$29.93
|
| Rate for Payer: Blue Shield of California EPN |
$19.55
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Central Health Plan Commercial |
$39.19
|
| Rate for Payer: Cigna of CA HMO |
$34.29
|
| Rate for Payer: Cigna of CA PPO |
$34.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$41.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$41.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.60
|
| Rate for Payer: EPIC Health Plan Senior |
$19.60
|
| Rate for Payer: Galaxy Health WC |
$41.64
|
| Rate for Payer: Global Benefits Group Commercial |
$29.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.09
|
| Rate for Payer: InnovAge PACE Commercial |
$24.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.29
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Networks By Design Commercial |
$31.84
|
| Rate for Payer: Prime Health Services Commercial |
$41.64
|
| Rate for Payer: Riverside University Health System MISP |
$19.60
|
| 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
|
$19.97
|
|
|
Service Code
|
NDC 82182-455-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$17.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Blue Shield of California Commercial |
$15.44
|
| Rate for Payer: Blue Shield of California EPN |
$10.06
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Central Health Plan Commercial |
$15.98
|
| Rate for Payer: Cigna of CA HMO |
$13.98
|
| Rate for Payer: Cigna of CA PPO |
$13.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.99
|
| Rate for Payer: EPIC Health Plan Senior |
$7.99
|
| Rate for Payer: Galaxy Health WC |
$16.97
|
| Rate for Payer: Global Benefits Group Commercial |
$11.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.97
|
| 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 |
$3.99
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Networks By Design Commercial |
$12.98
|
| Rate for Payer: Prime Health Services Commercial |
$16.97
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$19.97
|
|
|
Service Code
|
NDC 82182-455-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$17.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.13
|
| 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 Exchange |
$9.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.73
|
| Rate for Payer: Blue Shield of California Commercial |
$12.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.97
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Central Health Plan Commercial |
$15.98
|
| 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: Health Management Network EPO/PPO |
$17.97
|
| Rate for Payer: InnovAge PACE Commercial |
$9.98
|
| 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 |
$3.99
|
| 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 |
$14.98
|
| Rate for Payer: Networks By Design Commercial |
$12.98
|
| Rate for Payer: Prime Health Services Commercial |
$16.97
|
| Rate for Payer: Riverside University Health System MISP |
$7.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.98
|
| Rate for Payer: United Healthcare All Other HMO |
$9.98
|
| Rate for Payer: United Healthcare HMO Rider |
$9.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Vantage Medical Group Senior |
$16.97
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$30.72
|
|
|
Service Code
|
NDC 0832-1425-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: Adventist Health Commercial |
$6.14
|
| Rate for Payer: Blue Shield of California Commercial |
$23.75
|
| Rate for Payer: Blue Shield of California EPN |
$15.48
|
| Rate for Payer: Cash Price |
$16.89
|
| Rate for Payer: Central Health Plan Commercial |
$24.58
|
| Rate for Payer: Cigna of CA HMO |
$21.50
|
| Rate for Payer: Cigna of CA PPO |
$21.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.29
|
| Rate for Payer: EPIC Health Plan Senior |
$12.29
|
| Rate for Payer: Galaxy Health WC |
$26.11
|
| Rate for Payer: Global Benefits Group Commercial |
$18.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.14
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
| Rate for Payer: Networks By Design Commercial |
$19.97
|
| Rate for Payer: Prime Health Services Commercial |
$26.11
|
|
|
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 |
$33.33 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.49
|
| 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 Exchange |
$17.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.75
|
| Rate for Payer: Blue Shield of California Commercial |
$22.63
|
| Rate for Payer: Blue Shield of California EPN |
$14.77
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Central Health Plan Commercial |
$29.62
|
| 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: Health Management Network EPO/PPO |
$33.33
|
| Rate for Payer: InnovAge PACE Commercial |
$18.52
|
| 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 |
$7.41
|
| 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 |
$27.77
|
| Rate for Payer: Networks By Design Commercial |
$24.07
|
| Rate for Payer: Prime Health Services Commercial |
$31.48
|
| Rate for Payer: Riverside University Health System MISP |
$14.81
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$31.63 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.34
|
| 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 Exchange |
$17.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.64
|
| Rate for Payer: Blue Shield of California Commercial |
$21.47
|
| Rate for Payer: Blue Shield of California EPN |
$14.02
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Central Health Plan Commercial |
$28.11
|
| 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: Health Management Network EPO/PPO |
$31.63
|
| Rate for Payer: InnovAge PACE Commercial |
$17.57
|
| 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 |
$7.03
|
| 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 |
$26.36
|
| Rate for Payer: Networks By Design Commercial |
$22.84
|
| Rate for Payer: Prime Health Services Commercial |
$29.87
|
| Rate for Payer: Riverside University Health System MISP |
$14.06
|
| 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 |
$33.33 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California Commercial |
$28.62
|
| Rate for Payer: Blue Shield of California EPN |
$18.66
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Central Health Plan Commercial |
$29.62
|
| 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: Health Management Network EPO/PPO |
$33.33
|
| 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 |
$7.41
|
| Rate for Payer: Multiplan Commercial |
$27.77
|
| 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 |
$31.63 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Blue Shield of California Commercial |
$27.16
|
| Rate for Payer: Blue Shield of California EPN |
$17.71
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Central Health Plan Commercial |
$28.11
|
| 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: Health Management Network EPO/PPO |
$31.63
|
| 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 |
$7.03
|
| Rate for Payer: Multiplan Commercial |
$26.36
|
| Rate for Payer: Networks By Design Commercial |
$22.84
|
| Rate for Payer: Prime Health Services Commercial |
$29.87
|
|
|
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 |
$26.51 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.89
|
| 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 Exchange |
$14.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.30
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$11.75
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.57
|
| 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: Health Management Network EPO/PPO |
$26.51
|
| Rate for Payer: InnovAge PACE Commercial |
$14.73
|
| 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 |
$5.89
|
| 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 |
$22.09
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
| Rate for Payer: Riverside University Health System MISP |
$11.78
|
| 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 |
$26.51 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Blue Shield of California Commercial |
$22.77
|
| Rate for Payer: Blue Shield of California EPN |
$14.85
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.57
|
| 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: Health Management Network EPO/PPO |
$26.51
|
| 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 |
$5.89
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
| 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
|
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 |
$5.30 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.58
|
| 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 Exchange |
$2.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.46
|
| Rate for Payer: Blue Shield of California Commercial |
$3.60
|
| Rate for Payer: Blue Shield of California EPN |
$2.35
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Central Health Plan Commercial |
$4.71
|
| 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: Health Management Network EPO/PPO |
$5.30
|
| Rate for Payer: InnovAge PACE Commercial |
$2.94
|
| 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 |
$1.18
|
| 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 |
$4.42
|
| Rate for Payer: Networks By Design Commercial |
$3.83
|
| Rate for Payer: Prime Health Services Commercial |
$5.01
|
| Rate for Payer: Riverside University Health System MISP |
$2.36
|
| 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 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 |
$5.30 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$4.55
|
| Rate for Payer: Blue Shield of California EPN |
$2.97
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Central Health Plan Commercial |
$4.71
|
| 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: Health Management Network EPO/PPO |
$5.30
|
| 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 |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
| Rate for Payer: Networks By Design Commercial |
$3.83
|
| Rate for Payer: Prime Health Services Commercial |
$5.01
|
|
|
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 |
$13.63 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$11.71
|
| Rate for Payer: Blue Shield of California EPN |
$7.64
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Central Health Plan Commercial |
$12.12
|
| 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: Health Management Network EPO/PPO |
$13.63
|
| 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 |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
| 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/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 |
$13.63 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.20
|
| 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 Exchange |
$7.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.90
|
| Rate for Payer: Blue Shield of California Commercial |
$9.26
|
| Rate for Payer: Blue Shield of California EPN |
$6.04
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Central Health Plan Commercial |
$12.12
|
| 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: Health Management Network EPO/PPO |
$13.63
|
| Rate for Payer: InnovAge PACE Commercial |
$7.58
|
| 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 |
$3.03
|
| 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 |
$11.36
|
| Rate for Payer: Networks By Design Commercial |
$7.58
|
| Rate for Payer: Prime Health Services Commercial |
$12.88
|
| Rate for Payer: Riverside University Health System MISP |
$6.06
|
| 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 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 |
$26.51 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.89
|
| 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 Exchange |
$14.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.30
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$11.75
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.57
|
| 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: Health Management Network EPO/PPO |
$26.51
|
| Rate for Payer: InnovAge PACE Commercial |
$14.73
|
| 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 |
$5.89
|
| 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 |
$22.09
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
| Rate for Payer: Riverside University Health System MISP |
$11.78
|
| 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
|
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 |
$26.51 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.89
|
| 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 Exchange |
$14.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.30
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$11.75
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.57
|
| 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: Health Management Network EPO/PPO |
$26.51
|
| Rate for Payer: InnovAge PACE Commercial |
$14.73
|
| 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 |
$5.89
|
| 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 |
$22.09
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
| Rate for Payer: Riverside University Health System MISP |
$11.78
|
| 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 |
$26.51 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Blue Shield of California Commercial |
$22.77
|
| Rate for Payer: Blue Shield of California EPN |
$14.85
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Central Health Plan Commercial |
$23.57
|
| 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: Health Management Network EPO/PPO |
$26.51
|
| 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 |
$5.89
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
| Rate for Payer: Networks By Design Commercial |
$19.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.04
|
|
