|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 5047487015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.95
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.74
|
| Rate for Payer: Heritage Provider Network Senior |
$3.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.42
|
| Rate for Payer: TriValley Medical Group Senior |
$2.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.77
|
| Rate for Payer: Blue Shield of California Commercial |
$9.48
|
| Rate for Payer: Blue Shield of California EPN |
$7.58
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.20
|
| Rate for Payer: Heritage Provider Network Senior |
$7.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.88
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.22
|
| Rate for Payer: TriValley Medical Group Senior |
$6.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.01
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.20
|
| Rate for Payer: Heritage Provider Network Senior |
$7.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.15
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7220526906
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$30.23
|
|
|
Service Code
|
NDC 5047457009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$22.67 |
| Rate for Payer: Adventist Health Commercial |
$6.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.47
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.47
|
| Rate for Payer: Heritage Provider Network Senior |
$20.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.56
|
| Rate for Payer: Multiplan Commercial |
$22.67
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7220526901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7220526901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
OP
|
$30.22
|
|
|
Service Code
|
NDC 5047457066
|
| 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 50 MG TABLET [214047]
|
Facility
|
OP
|
$30.23
|
|
|
Service Code
|
NDC 5047457009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$25.70 |
| Rate for Payer: Adventist Health Commercial |
$6.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.12
|
| Rate for Payer: Blue Shield of California Commercial |
$18.44
|
| 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 |
$19.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.35
|
| 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 |
$14.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$22.67
|
| 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 |
$15.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.70
|
| Rate for Payer: Vantage Medical Group Senior |
$25.70
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
|
IP
|
$30.22
|
|
|
Service Code
|
NDC 5047457066
|
| 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 50 MG TABLET [214047]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7220526906
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
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 Non-Gatekeeper |
$62.15
|
| 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 |
$45.25
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$47.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
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: Aetna of CA Non-Gatekeeper |
$64.76
|
| Rate for Payer: Cash Price |
$45.25
|
| 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 Foundation Hospitals 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
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 7095497820
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 0574010603
|
| 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 Non-Gatekeeper |
$2.45
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.99
|
| 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 |
$1.79
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$3.60
|
|
|
Service Code
|
NDC 7095497820
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 6330496230
|
| 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: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Cash Price |
$1.79
|
| 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 Foundation Hospitals 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 7095497810
|
| 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 Non-Gatekeeper |
$2.45
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.99
|
| 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 |
$1.79
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 6330496230
|
| 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 Non-Gatekeeper |
$2.45
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.99
|
| 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 |
$1.79
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 7095497810
|
| 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: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Cash Price |
$1.79
|
| 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 Foundation Hospitals 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
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 0574010603
|
| 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: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Cash Price |
$1.79
|
| 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 Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
|
|
BRONCHITIS AND ASTHMA WITH CC/MCC
|
Facility
|
IP
|
$15,614.81
|
|
|
Service Code
|
MSDRG 202
|
| Min. Negotiated Rate |
$11,652.84 |
| Max. Negotiated Rate |
$15,614.81 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,652.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,652.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,400.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,614.81
|
|
|
BRONCHITIS AND ASTHMA WITHOUT CC/MCC
|
Facility
|
IP
|
$10,989.78
|
|
|
Service Code
|
MSDRG 203
|
| Min. Negotiated Rate |
$8,201.33 |
| Max. Negotiated Rate |
$10,989.78 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,201.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,201.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,431.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,989.78
|
|
|
BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 31625
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$2,289.25 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,433.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,518.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,289.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,433.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,518.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,289.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,289.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2,815.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,289.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,349.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,632.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,067.59
|
| Rate for Payer: Multiplan WC |
$3,491.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,518.18
|
| Rate for Payer: TriValley Medical Group Senior |
$2,518.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,433.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,518.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2,289.25
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]
|
Facility
|
OP
|
$1.10
|
|
|
Service Code
|
NDC 6909731886
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
