|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$19.97
|
|
|
Service Code
|
NDC 8218245505
|
| 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 |
$16.02
|
| Rate for Payer: Blue Shield of California EPN |
$10.06
|
| Rate for Payer: Cash Price |
$8.99
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$12.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.78
|
| 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
|
$30.72
|
|
|
Service Code
|
NDC 0832142505
|
| 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 |
$17.87
|
| Rate for Payer: Blue Shield of California Commercial |
$19.48
|
| Rate for Payer: Blue Shield of California EPN |
$12.26
|
| Rate for Payer: Cash Price |
$13.82
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$19.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023921105
|
| 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 |
$28.50
|
| Rate for Payer: Blue Shield of California Commercial |
$31.06
|
| Rate for Payer: Blue Shield of California EPN |
$19.55
|
| Rate for Payer: Cash Price |
$22.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$31.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$30.72
|
|
|
Service Code
|
NDC 0832142505
|
| 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 |
$24.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.48
|
| Rate for Payer: Cash Price |
$13.82
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$19.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.12
|
| 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
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$48.99
|
|
|
Service Code
|
NDC 0023921105
|
| 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 |
$39.29
|
| Rate for Payer: Blue Shield of California EPN |
$24.69
|
| Rate for Payer: Cash Price |
$22.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$31.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.90
|
| 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
|
$19.97
|
|
|
Service Code
|
NDC 8218245505
|
| 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 |
$11.62
|
| Rate for Payer: Blue Shield of California Commercial |
$12.66
|
| Rate for Payer: Blue Shield of California EPN |
$7.97
|
| Rate for Payer: Cash Price |
$8.99
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$12.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$35.14
|
|
|
Service Code
|
NDC 0781601470
|
| 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 |
$20.44
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$14.02
|
| Rate for Payer: Cash Price |
$15.81
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$22.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 6868246410
|
| 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 |
$29.70
|
| Rate for Payer: Blue Shield of California EPN |
$18.66
|
| Rate for Payer: Cash Price |
$16.66
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$23.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.85
|
| 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 0781601470
|
| 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 |
$28.18
|
| Rate for Payer: Blue Shield of California EPN |
$17.71
|
| Rate for Payer: Cash Price |
$15.81
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$22.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20.73
|
| 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
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$37.03
|
|
|
Service Code
|
NDC 6868246410
|
| 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 |
$21.54
|
| Rate for Payer: Blue Shield of California Commercial |
$23.48
|
| Rate for Payer: Blue Shield of California EPN |
$14.77
|
| Rate for Payer: Cash Price |
$16.66
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$23.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 7220527101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$30.22
|
|
|
Service Code
|
NDC 5047477066
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: Adventist Health Commercial |
$6.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.58
|
| Rate for Payer: Blue Shield of California Commercial |
$19.16
|
| Rate for Payer: Blue Shield of California EPN |
$12.06
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Central Health Plan Commercial |
$24.18
|
| Rate for Payer: Cigna of CA HMO |
$21.15
|
| Rate for Payer: Cigna of CA PPO |
$21.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.09
|
| Rate for Payer: EPIC Health Plan Senior |
$12.09
|
| Rate for Payer: Galaxy Health WC |
$25.69
|
| Rate for Payer: Global Benefits Group Commercial |
$18.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$22.66
|
| Rate for Payer: Networks By Design Commercial |
$19.64
|
| Rate for Payer: Prime Health Services Commercial |
$25.69
|
| Rate for Payer: Riverside University Health System MISP |
$12.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.11
|
| Rate for Payer: United Healthcare All Other HMO |
$15.11
|
| Rate for Payer: United Healthcare HMO Rider |
$15.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.69
|
| Rate for Payer: Vantage Medical Group Senior |
$25.69
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 7220527106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 7220527101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$30.22
|
|
|
Service Code
|
NDC 5047477066
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: Adventist Health Commercial |
$6.04
|
| Rate for Payer: Blue Shield of California Commercial |
$24.24
|
| Rate for Payer: Blue Shield of California EPN |
$15.23
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Central Health Plan Commercial |
$24.18
|
| Rate for Payer: Cigna of CA HMO |
$21.15
|
| Rate for Payer: Cigna of CA PPO |
$21.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.09
|
| Rate for Payer: EPIC Health Plan Senior |
$12.09
|
| Rate for Payer: Galaxy Health WC |
$25.69
|
| Rate for Payer: Global Benefits Group Commercial |
$18.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.04
|
| Rate for Payer: Multiplan Commercial |
$22.66
|
| Rate for Payer: Networks By Design Commercial |
$19.64
|
| Rate for Payer: Prime Health Services Commercial |
$25.69
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 7220527106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 5047487015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| Rate for Payer: Cigna of CA HMO |
$4.23
|
| Rate for Payer: Cigna of CA PPO |
$4.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 5047487015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.41
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| Rate for Payer: Cigna of CA HMO |
$4.23
|
| Rate for Payer: Cigna of CA PPO |
$4.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Riverside University Health System MISP |
$2.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Blue Shield of California Commercial |
$12.46
|
| Rate for Payer: Blue Shield of California EPN |
$7.83
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Central Health Plan Commercial |
$12.43
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Senior |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.11
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.83
|
| Rate for Payer: United Healthcare All Other HMO |
$5.68
|
| Rate for Payer: United Healthcare HMO Rider |
$5.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.09
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.04
|
| Rate for Payer: Blue Shield of California Commercial |
$9.85
|
| Rate for Payer: Blue Shield of California EPN |
$6.20
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Central Health Plan Commercial |
$12.43
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Senior |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.88
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: Riverside University Health System MISP |
$6.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.83
|
| Rate for Payer: United Healthcare All Other HMO |
$5.68
|
| Rate for Payer: United Healthcare HMO Rider |
$5.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$30.22
|
|
|
Service Code
|
NDC 5047457066
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: Adventist Health Commercial |
$6.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.58
|
| Rate for Payer: Blue Shield of California Commercial |
$19.16
|
| Rate for Payer: Blue Shield of California EPN |
$12.06
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Central Health Plan Commercial |
$24.18
|
| Rate for Payer: Cigna of CA HMO |
$21.15
|
| Rate for Payer: Cigna of CA PPO |
$21.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.09
|
| Rate for Payer: EPIC Health Plan Senior |
$12.09
|
| Rate for Payer: Galaxy Health WC |
$25.69
|
| Rate for Payer: Global Benefits Group Commercial |
$18.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$22.66
|
| Rate for Payer: Networks By Design Commercial |
$19.64
|
| Rate for Payer: Prime Health Services Commercial |
$25.69
|
| Rate for Payer: Riverside University Health System MISP |
$12.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.11
|
| Rate for Payer: United Healthcare All Other HMO |
$15.11
|
| Rate for Payer: United Healthcare HMO Rider |
$15.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.69
|
| Rate for Payer: Vantage Medical Group Senior |
$25.69
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7220526901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Riverside University Health System MISP |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$30.22
|
|
|
Service Code
|
NDC 5047457066
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: Adventist Health Commercial |
$6.04
|
| Rate for Payer: Blue Shield of California Commercial |
$24.24
|
| Rate for Payer: Blue Shield of California EPN |
$15.23
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Central Health Plan Commercial |
$24.18
|
| Rate for Payer: Cigna of CA HMO |
$21.15
|
| Rate for Payer: Cigna of CA PPO |
$21.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.09
|
| Rate for Payer: EPIC Health Plan Senior |
$12.09
|
| Rate for Payer: Galaxy Health WC |
$25.69
|
| Rate for Payer: Global Benefits Group Commercial |
$18.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.04
|
| Rate for Payer: Multiplan Commercial |
$22.66
|
| Rate for Payer: Networks By Design Commercial |
$19.64
|
| Rate for Payer: Prime Health Services Commercial |
$25.69
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$30.23
|
|
|
Service Code
|
NDC 5047457009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$27.21 |
| Rate for Payer: Adventist Health Commercial |
$6.05
|
| Rate for Payer: Blue Shield of California Commercial |
$24.24
|
| Rate for Payer: Blue Shield of California EPN |
$15.24
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Central Health Plan Commercial |
$24.18
|
| Rate for Payer: Cigna of CA HMO |
$21.16
|
| Rate for Payer: Cigna of CA PPO |
$21.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.09
|
| Rate for Payer: EPIC Health Plan Senior |
$12.09
|
| Rate for Payer: Galaxy Health WC |
$25.70
|
| Rate for Payer: Global Benefits Group Commercial |
$18.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$27.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$22.67
|
| Rate for Payer: Networks By Design Commercial |
$19.65
|
| Rate for Payer: Prime Health Services Commercial |
$25.70
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7220526901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
