|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
IP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$201.21 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.63
|
| Rate for Payer: Heritage Provider Network Senior |
$181.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
|
|
BOSENTAN CRUSHED TABLET IN WATER [40831875]
|
Facility
|
OP
|
$268.28
|
|
|
Service Code
|
NDC 66215-101-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$228.04 |
| Rate for Payer: Adventist Health Commercial |
$53.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$201.21
|
| Rate for Payer: Blue Shield of California Commercial |
$163.65
|
| Rate for Payer: Blue Shield of California EPN |
$130.92
|
| Rate for Payer: Cash Price |
$147.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.04
|
| Rate for Payer: Dignity Health Senior |
$228.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.07
|
| Rate for Payer: Heritage Provider Network Senior |
$166.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$127.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$187.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$187.80
|
| Rate for Payer: Multiplan Commercial |
$201.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.31
|
| Rate for Payer: TriValley Medical Group Senior |
$107.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.04
|
| Rate for Payer: Vantage Medical Group Senior |
$228.04
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
IP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.13
|
| Rate for Payer: Heritage Provider Network Senior |
$11.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
|
|
BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]
|
Facility
|
OP
|
$16.44
|
|
|
Service Code
|
NDC 9940-8318-76
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.33
|
| Rate for Payer: Blue Shield of California Commercial |
$10.03
|
| Rate for Payer: Blue Shield of California EPN |
$8.02
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.97
|
| Rate for Payer: Dignity Health Senior |
$13.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.18
|
| Rate for Payer: Heritage Provider Network Senior |
$10.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.51
|
| Rate for Payer: Multiplan Commercial |
$12.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.58
|
| Rate for Payer: TriValley Medical Group Senior |
$6.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.97
|
| Rate for Payer: Vantage Medical Group Senior |
$13.97
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
IP
|
$214.96
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.91 |
| Max. Negotiated Rate |
$161.22 |
| Rate for Payer: Adventist Health Commercial |
$42.99
|
| Rate for Payer: Cash Price |
$118.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$145.53
|
| Rate for Payer: Heritage Provider Network Senior |
$145.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.74
|
| Rate for Payer: Multiplan Commercial |
$161.22
|
|
|
BOSUTINIB 100 MG TABLET [197246]
|
Facility
|
OP
|
$214.96
|
|
|
Service Code
|
NDC 0069-0135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.91 |
| Max. Negotiated Rate |
$182.72 |
| Rate for Payer: Adventist Health Commercial |
$42.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$114.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$147.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$182.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$161.22
|
| Rate for Payer: Blue Shield of California Commercial |
$131.13
|
| Rate for Payer: Blue Shield of California EPN |
$104.90
|
| Rate for Payer: Cash Price |
$118.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$139.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$182.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.72
|
| Rate for Payer: Dignity Health Senior |
$182.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$133.06
|
| Rate for Payer: Heritage Provider Network Senior |
$133.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$102.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$150.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$150.47
|
| Rate for Payer: Multiplan Commercial |
$161.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$85.98
|
| Rate for Payer: TriValley Medical Group Senior |
$85.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$107.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$107.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$182.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.72
|
| Rate for Payer: Vantage Medical Group Senior |
$182.72
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
IP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.63 |
| Max. Negotiated Rate |
$644.87 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$464.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$582.10
|
| Rate for Payer: Heritage Provider Network Senior |
$582.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$214.96
|
| Rate for Payer: Multiplan Commercial |
$644.87
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
OP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0193-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.63 |
| Max. Negotiated Rate |
$730.86 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$459.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$590.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$472.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$644.87
|
| Rate for Payer: Blue Shield of California Commercial |
$524.50
|
| Rate for Payer: Blue Shield of California EPN |
$419.60
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$558.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$730.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$730.86
|
| Rate for Payer: Dignity Health Senior |
$730.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$550.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$532.23
|
| Rate for Payer: Heritage Provider Network Senior |
$532.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$410.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$214.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$601.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.88
|
| Rate for Payer: Multiplan Commercial |
$644.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$343.93
|
| Rate for Payer: TriValley Medical Group Senior |
$343.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$429.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$429.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$730.86
|
| Rate for Payer: Vantage Medical Group Senior |
$730.86
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
OP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.63 |
| Max. Negotiated Rate |
$730.86 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$459.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$590.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$472.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$644.87
|
| Rate for Payer: Blue Shield of California Commercial |
$524.50
|
| Rate for Payer: Blue Shield of California EPN |
$419.60
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$558.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$730.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$730.86
|
| Rate for Payer: Dignity Health Senior |
$730.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$550.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$532.23
|
| Rate for Payer: Heritage Provider Network Senior |
$532.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$410.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$214.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$601.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$601.88
|
| Rate for Payer: Multiplan Commercial |
$644.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$343.93
|
| Rate for Payer: TriValley Medical Group Senior |
$343.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$429.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$429.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$730.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$730.86
|
| Rate for Payer: Vantage Medical Group Senior |
$730.86
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
IP
|
$859.83
|
|
|
Service Code
|
NDC 0069-0136-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$155.63 |
| Max. Negotiated Rate |
$644.87 |
| Rate for Payer: Adventist Health Commercial |
$171.97
|
| Rate for Payer: Cash Price |
$472.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$464.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$582.10
|
| Rate for Payer: Heritage Provider Network Senior |
$582.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$214.96
|
| Rate for Payer: Multiplan Commercial |
$644.87
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$49.75
|
|
|
Service Code
|
NDC 0023-9177-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$42.29 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.31
|
| Rate for Payer: Blue Shield of California Commercial |
$30.35
|
| Rate for Payer: Blue Shield of California EPN |
$24.28
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.29
|
| Rate for Payer: Dignity Health Senior |
$42.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.80
|
| Rate for Payer: Heritage Provider Network Senior |
$30.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.83
|
| Rate for Payer: Multiplan Commercial |
$37.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.90
|
| Rate for Payer: TriValley Medical Group Senior |
$19.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.29
|
| Rate for Payer: Vantage Medical Group Senior |
$42.29
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.60
|
| Rate for Payer: Blue Shield of California Commercial |
$22.45
|
| Rate for Payer: Blue Shield of California EPN |
$17.96
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.28
|
| Rate for Payer: Dignity Health Senior |
$31.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.78
|
| Rate for Payer: Heritage Provider Network Senior |
$22.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$27.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.72
|
| Rate for Payer: TriValley Medical Group Senior |
$14.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.28
|
| Rate for Payer: Vantage Medical Group Senior |
$31.28
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$49.75
|
|
|
Service Code
|
NDC 0023-9177-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$37.31 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.68
|
| Rate for Payer: Heritage Provider Network Senior |
$33.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.44
|
| Rate for Payer: Multiplan Commercial |
$37.31
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$36.80
|
|
|
Service Code
|
NDC 61314-144-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.66 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.91
|
| Rate for Payer: Heritage Provider Network Senior |
$24.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.20
|
| Rate for Payer: Multiplan Commercial |
$27.60
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 70069-231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 70069-231-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Senior |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.59
|
| Rate for Payer: TriValley Medical Group Senior |
$0.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$19.97
|
|
|
Service Code
|
NDC 82182-455-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.72
|
| 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: Blue Shield of California Commercial |
$12.18
|
| Rate for Payer: Blue Shield of California EPN |
$9.75
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.97
|
| Rate for Payer: Dignity Health Senior |
$16.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.36
|
| Rate for Payer: Heritage Provider Network Senior |
$12.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.98
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.99
|
| Rate for Payer: TriValley Medical Group Senior |
$7.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Vantage Medical Group Senior |
$16.97
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$41.64 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.66
|
| 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: Blue Shield of California Commercial |
$29.88
|
| Rate for Payer: Blue Shield of California EPN |
$23.91
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$41.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$41.64
|
| Rate for Payer: Dignity Health Senior |
$41.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.32
|
| Rate for Payer: Heritage Provider Network Senior |
$30.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.29
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.60
|
| Rate for Payer: TriValley Medical Group Senior |
$19.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.64
|
| Rate for Payer: Vantage Medical Group Senior |
$41.64
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$36.74 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Cash Price |
$26.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.17
|
| Rate for Payer: Heritage Provider Network Senior |
$33.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$19.97
|
|
|
Service Code
|
NDC 82182-455-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.52
|
| Rate for Payer: Heritage Provider Network Senior |
$13.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$30.72
|
|
|
Service Code
|
NDC 0832-1425-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$26.11 |
| Rate for Payer: Adventist Health Commercial |
$6.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.10
|
| 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: Blue Shield of California Commercial |
$18.74
|
| Rate for Payer: Blue Shield of California EPN |
$14.99
|
| Rate for Payer: Cash Price |
$16.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.11
|
| Rate for Payer: Dignity Health Senior |
$26.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.02
|
| Rate for Payer: Heritage Provider Network Senior |
$19.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.29
|
| Rate for Payer: TriValley Medical Group Senior |
$12.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.11
|
| Rate for Payer: Vantage Medical Group Senior |
$26.11
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
IP
|
$30.72
|
|
|
Service Code
|
NDC 0832-1425-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$23.04 |
| Rate for Payer: Adventist Health Commercial |
$6.14
|
| Rate for Payer: Cash Price |
$16.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.80
|
| Rate for Payer: Heritage Provider Network Senior |
$20.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.68
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$29.87 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.14
|
| 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: Blue Shield of California Commercial |
$21.44
|
| Rate for Payer: Blue Shield of California EPN |
$17.15
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.87
|
| Rate for Payer: Dignity Health Senior |
$29.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.75
|
| Rate for Payer: Heritage Provider Network Senior |
$21.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.60
|
| Rate for Payer: Multiplan Commercial |
$26.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.06
|
| Rate for Payer: TriValley Medical Group Senior |
$14.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$26.36 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.79
|
| Rate for Payer: Heritage Provider Network Senior |
$23.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.79
|
| Rate for Payer: Multiplan Commercial |
$26.36
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
OP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$31.48 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.44
|
| 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: Blue Shield of California Commercial |
$22.59
|
| Rate for Payer: Blue Shield of California EPN |
$18.07
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.48
|
| Rate for Payer: Dignity Health Senior |
$31.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.92
|
| Rate for Payer: Heritage Provider Network Senior |
$22.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.92
|
| Rate for Payer: Multiplan Commercial |
$27.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.81
|
| Rate for Payer: TriValley Medical Group Senior |
$14.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
