|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
IP
|
$42.55
|
|
|
Service Code
|
NDC 60505-0589-1
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$38.30 |
| Rate for Payer: Blue Shield of California Commercial |
$31.91
|
| Rate for Payer: Blue Shield of California EPN |
$22.72
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Central Health Plan Commercial |
$34.04
|
| Rate for Payer: Cigna of CA HMO |
$29.78
|
| Rate for Payer: Cigna of CA PPO |
$29.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.02
|
| Rate for Payer: Galaxy Health WC |
$36.17
|
| Rate for Payer: Global Benefits Group Commercial |
$25.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$38.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Commercial |
$31.91
|
| Rate for Payer: Networks By Design Commercial |
$27.66
|
| Rate for Payer: Prime Health Services Commercial |
$36.17
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$44.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$23.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.94
|
| Rate for Payer: BCBS Transplant Transplant |
$29.39
|
| Rate for Payer: Blue Shield of California Commercial |
$30.81
|
| Rate for Payer: Blue Shield of California EPN |
$23.96
|
| 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: EPIC Health Plan Commercial |
$19.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.60
|
| Rate for Payer: Galaxy Health WC |
$41.64
|
| Rate for Payer: Global Benefits Group Commercial |
$29.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$36.74
|
| Rate for Payer: IEHP medi-cal |
$17.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.68
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$29.39
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$41.64
|
| Rate for Payer: Vantage Medical Group Senior |
$41.64
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
IP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$25.75 |
| Rate for Payer: Blue Shield of California Commercial |
$21.46
|
| Rate for Payer: Blue Shield of California EPN |
$15.28
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Central Health Plan Commercial |
$22.89
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.44
|
| Rate for Payer: Galaxy Health WC |
$24.32
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.32
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
OP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$25.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.74
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.90
|
| Rate for Payer: BCBS Transplant Transplant |
$17.17
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$13.99
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Central Health Plan Commercial |
$22.89
|
| Rate for Payer: Cigna of CA HMO |
$20.03
|
| Rate for Payer: Cigna of CA PPO |
$20.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.44
|
| Rate for Payer: Galaxy Health WC |
$24.32
|
| Rate for Payer: Global Benefits Group Commercial |
$17.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$21.46
|
| Rate for Payer: IEHP medi-cal |
$10.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: Networks By Design Commercial |
$18.60
|
| Rate for Payer: Prime Health Services Commercial |
$24.32
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: Riverside University Health MISP |
$11.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.30
|
| Rate for Payer: United Healthcare All Other HMO |
$14.30
|
| Rate for Payer: United Healthcare HMO Rider |
$14.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.32
|
| Rate for Payer: Vantage Medical Group Senior |
$24.32
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
IP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$31.63 |
| Rate for Payer: Blue Shield of California Commercial |
$26.36
|
| Rate for Payer: Blue Shield of California EPN |
$18.76
|
| 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: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: Galaxy Health WC |
$29.87
|
| Rate for Payer: Global Benefits Group Commercial |
$21.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$31.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.44
|
| 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
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$31.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$29.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.76
|
| Rate for Payer: BCBS Transplant Transplant |
$21.08
|
| Rate for Payer: Blue Shield of California Commercial |
$22.10
|
| Rate for Payer: Blue Shield of California EPN |
$17.18
|
| 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: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.06
|
| Rate for Payer: Galaxy Health WC |
$29.87
|
| Rate for Payer: Global Benefits Group Commercial |
$21.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$31.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$26.36
|
| Rate for Payer: IEHP medi-cal |
$12.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.44
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$21.08
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$29.87
|
| Rate for Payer: Vantage Medical Group Senior |
$29.87
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
IP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$33.33 |
| Rate for Payer: Blue Shield of California Commercial |
$27.77
|
| Rate for Payer: Blue Shield of California EPN |
$19.77
|
| 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: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: Galaxy Health WC |
$31.48
|
| Rate for Payer: Global Benefits Group Commercial |
$22.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.70
|
| 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
OP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$33.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.88
|
| Rate for Payer: BCBS Transplant Transplant |
$22.22
|
| Rate for Payer: Blue Shield of California Commercial |
$23.29
|
| Rate for Payer: Blue Shield of California EPN |
$18.11
|
| 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: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.81
|
| Rate for Payer: Galaxy Health WC |
$31.48
|
| Rate for Payer: Global Benefits Group Commercial |
$22.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$27.77
|
| Rate for Payer: IEHP medi-cal |
$12.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.70
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$22.22
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$31.48
|
| Rate for Payer: Vantage Medical Group Senior |
$31.48
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
IP
|
$27.50
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
ERX214049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$24.75 |
| Rate for Payer: Blue Shield of California Commercial |
$20.62
|
| Rate for Payer: Blue Shield of California EPN |
$14.68
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Central Health Plan Commercial |
$22.00
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
OP
|
$27.50
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
ERX214049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$24.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.25
|
| Rate for Payer: BCBS Transplant Transplant |
$16.50
|
| Rate for Payer: Blue Shield of California Commercial |
$17.30
|
| Rate for Payer: Blue Shield of California EPN |
$13.45
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Central Health Plan Commercial |
$22.00
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20.62
|
| Rate for Payer: IEHP medi-cal |
$9.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$16.50
|
| Rate for Payer: Riverside University Health MISP |
$11.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.75
|
| Rate for Payer: United Healthcare All Other HMO |
$13.75
|
| Rate for Payer: United Healthcare HMO Rider |
$13.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.38
|
| Rate for Payer: Vantage Medical Group Senior |
$23.38
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
IP
|
$5.50
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
NDG214044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Blue Shield of California Commercial |
$4.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Central Health Plan Commercial |
$4.40
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.68
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
OP
|
$5.50
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
NDG214044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.25
|
| Rate for Payer: BCBS Transplant Transplant |
$3.30
|
| Rate for Payer: Blue Shield of California Commercial |
$3.46
|
| Rate for Payer: Blue Shield of California EPN |
$2.69
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Central Health Plan Commercial |
$4.40
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.12
|
| Rate for Payer: IEHP medi-cal |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.68
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: Riverside University Health MISP |
$2.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.75
|
| Rate for Payer: United Healthcare HMO Rider |
$2.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4.68
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
OP
|
$14.15
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG214043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.36
|
| Rate for Payer: BCBS Transplant Transplant |
$8.49
|
| Rate for Payer: Blue Shield of California Commercial |
$8.90
|
| Rate for Payer: Blue Shield of California EPN |
$6.92
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Central Health Plan Commercial |
$11.32
|
| Rate for Payer: Cigna of CA HMO |
$9.90
|
| Rate for Payer: Cigna of CA PPO |
$9.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.66
|
| Rate for Payer: Galaxy Health WC |
$12.03
|
| Rate for Payer: Global Benefits Group Commercial |
$8.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10.61
|
| Rate for Payer: IEHP medi-cal |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$10.61
|
| Rate for Payer: Networks By Design Commercial |
$7.08
|
| Rate for Payer: Prime Health Services Commercial |
$12.03
|
| Rate for Payer: Riverside University Health MISP |
$5.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.08
|
| Rate for Payer: United Healthcare All Other HMO |
$7.08
|
| Rate for Payer: United Healthcare HMO Rider |
$7.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.03
|
| Rate for Payer: Vantage Medical Group Senior |
$12.03
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
IP
|
$14.15
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG214043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Blue Shield of California Commercial |
$10.61
|
| Rate for Payer: Blue Shield of California EPN |
$7.56
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Central Health Plan Commercial |
$11.32
|
| Rate for Payer: Cigna of CA HMO |
$9.90
|
| Rate for Payer: Cigna of CA PPO |
$9.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.66
|
| Rate for Payer: Galaxy Health WC |
$12.03
|
| Rate for Payer: Global Benefits Group Commercial |
$8.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$10.61
|
| Rate for Payer: Networks By Design Commercial |
$7.08
|
| Rate for Payer: Prime Health Services Commercial |
$12.03
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
OP
|
$27.50
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
ERX214047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$24.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.25
|
| Rate for Payer: BCBS Transplant Transplant |
$16.50
|
| Rate for Payer: Blue Shield of California Commercial |
$17.30
|
| Rate for Payer: Blue Shield of California EPN |
$13.45
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Central Health Plan Commercial |
$22.00
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20.62
|
| Rate for Payer: IEHP medi-cal |
$9.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$16.50
|
| Rate for Payer: Riverside University Health MISP |
$11.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.75
|
| Rate for Payer: United Healthcare All Other HMO |
$13.75
|
| Rate for Payer: United Healthcare HMO Rider |
$13.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.38
|
| Rate for Payer: Vantage Medical Group Senior |
$23.38
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
IP
|
$27.50
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
ERX214047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$24.75 |
| Rate for Payer: Blue Shield of California Commercial |
$20.62
|
| Rate for Payer: Blue Shield of California EPN |
$14.68
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Central Health Plan Commercial |
$22.00
|
| Rate for Payer: Cigna of CA HMO |
$19.25
|
| Rate for Payer: Cigna of CA PPO |
$19.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.00
|
| Rate for Payer: Galaxy Health WC |
$23.38
|
| Rate for Payer: Global Benefits Group Commercial |
$16.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$24.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
| Rate for Payer: Networks By Design Commercial |
$17.88
|
| Rate for Payer: Prime Health Services Commercial |
$23.38
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
IP
|
$125.70
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.14 |
| Max. Negotiated Rate |
$113.13 |
| Rate for Payer: Blue Shield of California Commercial |
$94.28
|
| Rate for Payer: Blue Shield of California Commercial |
$75.42
|
| Rate for Payer: Blue Shield of California Commercial |
$94.27
|
| Rate for Payer: Blue Shield of California EPN |
$67.12
|
| Rate for Payer: Blue Shield of California EPN |
$67.12
|
| Rate for Payer: Blue Shield of California EPN |
$53.70
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Central Health Plan Commercial |
$100.56
|
| Rate for Payer: Central Health Plan Commercial |
$100.55
|
| Rate for Payer: Central Health Plan Commercial |
$80.45
|
| Rate for Payer: Cigna of CA HMO |
$87.99
|
| Rate for Payer: Cigna of CA HMO |
$70.39
|
| Rate for Payer: Cigna of CA HMO |
$87.98
|
| Rate for Payer: Cigna of CA PPO |
$87.98
|
| Rate for Payer: Cigna of CA PPO |
$70.39
|
| Rate for Payer: Cigna of CA PPO |
$87.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: Galaxy Health WC |
$85.48
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Global Benefits Group Commercial |
$60.34
|
| Rate for Payer: Global Benefits Group Commercial |
$75.41
|
| Rate for Payer: Global Benefits Group Commercial |
$75.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$113.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$113.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$94.28
|
| Rate for Payer: Multiplan Commercial |
$94.27
|
| Rate for Payer: Multiplan Commercial |
$75.42
|
| Rate for Payer: Networks By Design Commercial |
$62.85
|
| Rate for Payer: Networks By Design Commercial |
$62.84
|
| Rate for Payer: Networks By Design Commercial |
$50.28
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$85.48
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
OP
|
$125.69
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.14 |
| Max. Negotiated Rate |
$113.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$61.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$76.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$55.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.31
|
| Rate for Payer: BCBS Transplant Transplant |
$75.42
|
| Rate for Payer: BCBS Transplant Transplant |
$60.34
|
| Rate for Payer: BCBS Transplant Transplant |
$75.41
|
| Rate for Payer: Blue Shield of California Commercial |
$79.06
|
| Rate for Payer: Blue Shield of California Commercial |
$79.07
|
| Rate for Payer: Blue Shield of California Commercial |
$63.25
|
| Rate for Payer: Blue Shield of California EPN |
$61.47
|
| Rate for Payer: Blue Shield of California EPN |
$61.46
|
| Rate for Payer: Blue Shield of California EPN |
$49.17
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Central Health Plan Commercial |
$100.56
|
| Rate for Payer: Central Health Plan Commercial |
$80.45
|
| Rate for Payer: Central Health Plan Commercial |
$100.55
|
| Rate for Payer: Cigna of CA HMO |
$70.39
|
| Rate for Payer: Cigna of CA HMO |
$87.98
|
| Rate for Payer: Cigna of CA HMO |
$87.99
|
| Rate for Payer: Cigna of CA PPO |
$87.99
|
| Rate for Payer: Cigna of CA PPO |
$87.98
|
| Rate for Payer: Cigna of CA PPO |
$70.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.28
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Galaxy Health WC |
$106.84
|
| Rate for Payer: Galaxy Health WC |
$85.48
|
| Rate for Payer: Global Benefits Group Commercial |
$75.41
|
| Rate for Payer: Global Benefits Group Commercial |
$60.34
|
| Rate for Payer: Global Benefits Group Commercial |
$75.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$113.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$113.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$94.27
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$75.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$94.28
|
| Rate for Payer: IEHP medi-cal |
$35.20
|
| Rate for Payer: IEHP medi-cal |
$44.00
|
| Rate for Payer: IEHP medi-cal |
$43.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$75.42
|
| Rate for Payer: Multiplan Commercial |
$94.27
|
| Rate for Payer: Multiplan Commercial |
$94.28
|
| Rate for Payer: Networks By Design Commercial |
$62.84
|
| Rate for Payer: Networks By Design Commercial |
$50.28
|
| Rate for Payer: Networks By Design Commercial |
$62.85
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$106.84
|
| Rate for Payer: Prime Health Services Commercial |
$85.48
|
| Rate for Payer: Riverside University Health MISP |
$50.28
|
| Rate for Payer: Riverside University Health MISP |
$50.28
|
| Rate for Payer: Riverside University Health MISP |
$40.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$75.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$75.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$75.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$75.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$62.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$50.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$62.84
|
| Rate for Payer: United Healthcare All Other HMO |
$62.84
|
| Rate for Payer: United Healthcare All Other HMO |
$62.85
|
| Rate for Payer: United Healthcare All Other HMO |
$50.28
|
| Rate for Payer: United Healthcare HMO Rider |
$50.28
|
| Rate for Payer: United Healthcare HMO Rider |
$62.85
|
| Rate for Payer: United Healthcare HMO Rider |
$62.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$50.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$85.48
|
| Rate for Payer: Vantage Medical Group Senior |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$106.84
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.98
|
| Rate for Payer: IEHP medi-cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: Riverside University Health MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.98
|
| Rate for Payer: IEHP medi-cal |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: Riverside University Health MISP |
$1.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
IP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Blue Shield of California Commercial |
$4.52
|
| Rate for Payer: Blue Shield of California EPN |
$3.21
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Central Health Plan Commercial |
$4.82
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
OP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.56
|
| Rate for Payer: BCBS Transplant Transplant |
$3.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Central Health Plan Commercial |
$4.82
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.52
|
| Rate for Payer: IEHP medi-cal |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.61
|
| Rate for Payer: Riverside University Health MISP |
$2.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.01
|
| Rate for Payer: United Healthcare All Other HMO |
$3.01
|
| Rate for Payer: United Healthcare HMO Rider |
$3.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Vantage Medical Group Senior |
$5.12
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$3.18
|
| Rate for Payer: Cigna of CA HMO |
$2.78
|
| Rate for Payer: Cigna of CA PPO |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Galaxy Health WC |
$3.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.37
|
|
|
BROMPHENIRAMINE-PHENYLEPHRINE 1 MG-2.5 MG/5 ML ORAL SOLUTION [77434]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 49348-777-34
|
| Hospital Charge Code |
NDG77434
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
