|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]
|
Facility
|
IP
|
$16,420.56
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,972.12 |
| Max. Negotiated Rate |
$12,315.42 |
| Rate for Payer: Adventist Health Commercial |
$3,284.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10,574.84
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,553.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,867.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,602.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7,602.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,972.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,105.14
|
| Rate for Payer: Multiplan Commercial |
$12,315.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,932.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,436.85
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]
|
Facility
|
OP
|
$16,420.56
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$225.78 |
| Max. Negotiated Rate |
$12,315.42 |
| Rate for Payer: Adventist Health Commercial |
$3,284.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10,147.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$418.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$307.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$279.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$225.78
|
| Rate for Payer: Blue Shield of California Commercial |
$239.54
|
| Rate for Payer: Blue Shield of California EPN |
$239.54
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7,553.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$349.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$307.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$307.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,509.16
|
| Rate for Payer: EPIC Health Plan Medicare |
$279.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,602.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7,602.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$279.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,832.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,972.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$321.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,105.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$374.14
|
| Rate for Payer: Multiplan Commercial |
$12,315.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,568.22
|
| Rate for Payer: TriValley Medical Group Senior |
$6,568.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5,932.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5,436.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$349.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$307.13
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$49.75
|
|
|
Service Code
|
NDC 0023917705
|
| 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 Non-Gatekeeper |
$30.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.88
|
| 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 |
$22.39
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$23.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$49.75
|
|
|
Service Code
|
NDC 0023917705
|
| 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: Aetna of CA Non-Gatekeeper |
$32.04
|
| Rate for Payer: Cash Price |
$22.39
|
| 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 Foundation Hospitals 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
|
OP
|
$36.80
|
|
|
Service Code
|
NDC 6131414405
|
| 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 Non-Gatekeeper |
$22.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.41
|
| 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 |
$16.56
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$17.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$36.80
|
|
|
Service Code
|
NDC 6131414405
|
| 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: Aetna of CA Non-Gatekeeper |
$23.70
|
| Rate for Payer: Cash Price |
$16.56
|
| 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 Foundation Hospitals 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 7006923101
|
| 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: Aetna of CA Non-Gatekeeper |
$0.95
|
| Rate for Payer: Cash Price |
$0.66
|
| 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 Foundation Hospitals 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 7006923101
|
| 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 Non-Gatekeeper |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| 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 |
$0.66
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$19.97
|
|
|
Service Code
|
NDC 8218245505
|
| 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: Aetna of CA Non-Gatekeeper |
$12.86
|
| Rate for Payer: Cash Price |
$8.99
|
| 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 Foundation Hospitals 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
|
$48.99
|
|
|
Service Code
|
NDC 0023921105
|
| 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 Non-Gatekeeper |
$30.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.50
|
| 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 |
$22.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$23.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$30.72
|
|
|
Service Code
|
NDC 0832142505
|
| 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 Non-Gatekeeper |
$18.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.37
|
| 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 |
$13.82
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$14.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$48.99
|
|
|
Service Code
|
NDC 0023921105
|
| 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: Aetna of CA Non-Gatekeeper |
$31.55
|
| Rate for Payer: Cash Price |
$22.05
|
| 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 Foundation Hospitals 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
|
$30.72
|
|
|
Service Code
|
NDC 0832142505
|
| 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: Aetna of CA Non-Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$13.82
|
| 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 Foundation Hospitals Medi-Cal |
$5.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.68
|
| Rate for Payer: Multiplan Commercial |
$23.04
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
|
OP
|
$19.97
|
|
|
Service Code
|
NDC 8218245505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Adventist Health Commercial |
$3.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.99
|
| 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 |
$8.99
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$9.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
IP
|
$37.03
|
|
|
Service Code
|
NDC 6868246410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$27.77 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.85
|
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.07
|
| Rate for Payer: Heritage Provider Network Senior |
$25.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$27.77
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
|
IP
|
$35.14
|
|
|
Service Code
|
NDC 0781601470
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$26.36 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.63
|
| Rate for Payer: Cash Price |
$15.81
|
| 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 Foundation Hospitals 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
|
$35.14
|
|
|
Service Code
|
NDC 0781601470
|
| 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 Non-Gatekeeper |
$21.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.58
|
| 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 |
$15.81
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$16.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$37.03
|
|
|
Service Code
|
NDC 6868246410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$31.48 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.48
|
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.52
|
| 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 |
$16.66
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$17.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$31.48
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$30.22
|
|
|
Service Code
|
NDC 5047477066
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$22.66 |
| Rate for Payer: Adventist Health Commercial |
$6.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.46
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.46
|
| Rate for Payer: Heritage Provider Network Senior |
$20.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.55
|
| Rate for Payer: Multiplan Commercial |
$22.66
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$30.22
|
|
|
Service Code
|
NDC 5047477066
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Adventist Health Commercial |
$6.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.12
|
| Rate for Payer: Blue Shield of California Commercial |
$18.43
|
| Rate for Payer: Blue Shield of California EPN |
$14.75
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.71
|
| Rate for Payer: Heritage Provider Network Senior |
$18.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$22.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.09
|
| Rate for Payer: TriValley Medical Group Senior |
$12.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.69
|
| Rate for Payer: Vantage Medical Group Senior |
$25.69
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 7220527106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 7220527106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 7220527101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 7220527101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 5047487015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Senior |
$4.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
|
