|
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
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$22.09 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.94
|
| Rate for Payer: Heritage Provider Network Senior |
$19.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.09
|
| Rate for Payer: Blue Shield of California Commercial |
$17.97
|
| Rate for Payer: Blue Shield of California EPN |
$14.38
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.04
|
| Rate for Payer: Dignity Health Senior |
$25.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.24
|
| Rate for Payer: Heritage Provider Network Senior |
$18.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.78
|
| Rate for Payer: TriValley Medical Group Senior |
$11.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.04
|
| Rate for Payer: Vantage Medical Group Senior |
$25.04
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
OP
|
$5.89
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$5.01 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.42
|
| Rate for Payer: Blue Shield of California Commercial |
$3.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.87
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.01
|
| Rate for Payer: Dignity Health Senior |
$5.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.12
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.01
|
| Rate for Payer: Vantage Medical Group Senior |
$5.01
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
IP
|
$5.89
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
OP
|
$15.15
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$12.88 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.36
|
| Rate for Payer: Blue Shield of California Commercial |
$9.24
|
| Rate for Payer: Blue Shield of California EPN |
$7.39
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.88
|
| Rate for Payer: Dignity Health Senior |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.61
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.06
|
| Rate for Payer: TriValley Medical Group Senior |
$6.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.88
|
| Rate for Payer: Vantage Medical Group Senior |
$12.88
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
IP
|
$15.15
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$11.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.02
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$22.09 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.94
|
| Rate for Payer: Heritage Provider Network Senior |
$19.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.09
|
| Rate for Payer: Blue Shield of California Commercial |
$17.97
|
| Rate for Payer: Blue Shield of California EPN |
$14.38
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.04
|
| Rate for Payer: Dignity Health Senior |
$25.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.24
|
| Rate for Payer: Heritage Provider Network Senior |
$18.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.78
|
| Rate for Payer: TriValley Medical Group Senior |
$11.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.04
|
| Rate for Payer: Vantage Medical Group Senior |
$25.04
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$22.09 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.94
|
| Rate for Payer: Heritage Provider Network Senior |
$19.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$29.46
|
|
|
Service Code
|
NDC 50474-570-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$25.04 |
| Rate for Payer: Adventist Health Commercial |
$5.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.09
|
| Rate for Payer: Blue Shield of California Commercial |
$17.97
|
| Rate for Payer: Blue Shield of California EPN |
$14.38
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.04
|
| Rate for Payer: Dignity Health Senior |
$25.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.24
|
| Rate for Payer: Heritage Provider Network Senior |
$18.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$22.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.78
|
| Rate for Payer: TriValley Medical Group Senior |
$11.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.04
|
| Rate for Payer: Vantage Medical Group Senior |
$25.04
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
IP
|
$100.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$75.42 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.56
|
| Rate for Payer: Heritage Provider Network Senior |
$46.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$75.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.30
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
|
OP
|
$100.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$85.48 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.42
|
| Rate for Payer: Blue Shield of California Commercial |
$61.34
|
| Rate for Payer: Blue Shield of California EPN |
$49.07
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.48
|
| Rate for Payer: Dignity Health Senior |
$85.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.56
|
| Rate for Payer: Heritage Provider Network Senior |
$46.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$47.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.39
|
| Rate for Payer: Multiplan Commercial |
$75.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$40.22
|
| Rate for Payer: TriValley Medical Group Senior |
$40.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.48
|
| Rate for Payer: Vantage Medical Group Senior |
$85.48
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3.67
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.12
|
| Rate for Payer: Dignity Health Senior |
$5.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$4.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.41
|
| Rate for Payer: TriValley Medical Group Senior |
$2.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.12
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Senior |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Senior |
$1.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| 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
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.51
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.37
|
| Rate for Payer: Dignity Health Senior |
$3.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Senior |
$1.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.37
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 0093-6815-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.76
|
| Rate for Payer: Blue Shield of California EPN |
$2.21
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.84
|
| Rate for Payer: Dignity Health Senior |
$3.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.80
|
| Rate for Payer: Heritage Provider Network Senior |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.81
|
| Rate for Payer: TriValley Medical Group Senior |
$1.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Vantage Medical Group Senior |
$3.84
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
IP
|
$1.10
|
|
|
Service Code
|
NDC 69097-318-87
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 0093-6815-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.76
|
| Rate for Payer: Blue Shield of California EPN |
$2.21
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.84
|
| Rate for Payer: Dignity Health Senior |
$3.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.80
|
| Rate for Payer: Heritage Provider Network Senior |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.81
|
| Rate for Payer: TriValley Medical Group Senior |
$1.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Vantage Medical Group Senior |
$3.84
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 0093-6815-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.39 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 0093-6815-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.39 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$3.39
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
IP
|
$20.40
|
|
|
Service Code
|
NDC 0487-9601-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Adventist Health Commercial |
$4.08
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.81
|
| Rate for Payer: Heritage Provider Network Senior |
$13.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.10
|
| Rate for Payer: Multiplan Commercial |
$15.30
|
|
