|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
IP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
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 |
$33.66
|
| 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 Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
IP
|
$42.55
|
|
|
Service Code
|
NDC 60505-0589-1
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$31.91 |
| Rate for Payer: Adventist Health Commercial |
$8.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.23
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.81
|
| Rate for Payer: Heritage Provider Network Senior |
$28.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.64
|
| Rate for Payer: Multiplan Commercial |
$31.91
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
OP
|
$42.55
|
|
|
Service Code
|
NDC 60505-0589-1
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$36.17 |
| Rate for Payer: Adventist Health Commercial |
$8.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$36.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$31.91
|
| Rate for Payer: Blue Shield of California Commercial |
$26.42
|
| Rate for Payer: Blue Shield of California EPN |
$24.98
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.17
|
| Rate for Payer: Dignity Health Senior |
$36.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.34
|
| Rate for Payer: Heritage Provider Network Senior |
$26.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.64
|
| Rate for Payer: Multiplan Commercial |
$31.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.17
|
| Rate for Payer: Vantage Medical Group Senior |
$36.17
|
|
|
BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]
|
Facility
OP
|
$48.99
|
|
|
Service Code
|
NDC 0023-9211-05
|
| Hospital Charge Code |
NDG87834A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$41.64 |
| Rate for Payer: Adventist Health Commercial |
$9.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.74
|
| Rate for Payer: Blue Shield of California Commercial |
$30.42
|
| Rate for Payer: Blue Shield of California EPN |
$28.76
|
| 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 Senior |
$41.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.32
|
| Rate for Payer: Heritage Provider Network Senior |
$30.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$36.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$41.64
|
| Rate for Payer: Vantage Medical Group Senior |
$41.64
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
IP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.66
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.37
|
| Rate for Payer: Heritage Provider Network Senior |
$19.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.15
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
|
|
BRINZOLAMIDE 1 %-BRIMONIDINE 0.2 % EYE DROPS,SUSPENSION [201994]
|
Facility
OP
|
$28.61
|
|
|
Service Code
|
NDC 0078-0904-38
|
| Hospital Charge Code |
NDG201994A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$24.32 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Blue Shield of California Commercial |
$17.77
|
| Rate for Payer: Blue Shield of California EPN |
$16.79
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.32
|
| Rate for Payer: Dignity Health Senior |
$24.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.71
|
| Rate for Payer: Heritage Provider Network Senior |
$17.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.15
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.32
|
| Rate for Payer: Vantage Medical Group Senior |
$24.32
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
OP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
1740312
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$31.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.77
|
| Rate for Payer: Blue Shield of California Commercial |
$23.00
|
| Rate for Payer: Blue Shield of California EPN |
$21.74
|
| 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 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 |
$17.85
|
| 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: Multiplan Commercial |
$27.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.48
|
| Rate for Payer: Vantage Medical Group Senior |
$31.48
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
IP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$26.36 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.14
|
| 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 Permanente of CA Medi-Cal |
$6.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.78
|
| Rate for Payer: Multiplan Commercial |
$26.36
|
|
|
BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]
|
Facility
IP
|
$37.03
|
|
|
Service Code
|
NDC 68682-464-10
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$27.77 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.44
|
| 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 Permanente of CA 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
OP
|
$35.14
|
|
|
Service Code
|
NDC 0781-6014-70
|
| Hospital Charge Code |
1740312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$29.87 |
| Rate for Payer: Adventist Health Commercial |
$7.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$29.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.36
|
| Rate for Payer: Blue Shield of California Commercial |
$21.82
|
| Rate for Payer: Blue Shield of California EPN |
$20.63
|
| 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 Senior |
$29.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.75
|
| Rate for Payer: Heritage Provider Network Senior |
$21.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.78
|
| Rate for Payer: Multiplan Commercial |
$26.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.87
|
| Rate for Payer: Vantage Medical Group Senior |
$29.87
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
OP
|
$27.50
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
ERX214049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$23.38 |
| Rate for Payer: Adventist Health Commercial |
$5.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.62
|
| Rate for Payer: Blue Shield of California Commercial |
$17.08
|
| Rate for Payer: Blue Shield of California EPN |
$16.14
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.38
|
| Rate for Payer: Dignity Health Senior |
$23.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.02
|
| Rate for Payer: Heritage Provider Network Senior |
$17.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.88
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.38
|
| Rate for Payer: Vantage Medical Group Senior |
$23.38
|
|
|
BRIVARACETAM 100 MG TABLET [214049]
|
Facility
IP
|
$27.50
|
|
|
Service Code
|
NDC 50474-770-66
|
| Hospital Charge Code |
ERX214049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Adventist Health Commercial |
$5.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.89
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.62
|
| Rate for Payer: Heritage Provider Network Senior |
$18.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.88
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
OP
|
$5.50
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
NDG214044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.68
|
| Rate for Payer: Dignity Health Senior |
$4.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Senior |
$3.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4.68
|
|
|
BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]
|
Facility
IP
|
$5.50
|
|
|
Service Code
|
NDC 50474-870-15
|
| Hospital Charge Code |
NDG214044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.78
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
IP
|
$14.15
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG214043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$10.61 |
| Rate for Payer: Adventist Health Commercial |
$2.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.72
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.58
|
| Rate for Payer: Heritage Provider Network Senior |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$10.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.73
|
|
|
BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]
|
Facility
OP
|
$14.15
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG214043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$12.03 |
| Rate for Payer: Adventist Health Commercial |
$2.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.61
|
| Rate for Payer: Blue Shield of California Commercial |
$8.79
|
| Rate for Payer: Blue Shield of California EPN |
$8.31
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.03
|
| Rate for Payer: Dignity Health Senior |
$12.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.55
|
| Rate for Payer: Heritage Provider Network Senior |
$6.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$10.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.03
|
| Rate for Payer: Vantage Medical Group Senior |
$12.03
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
IP
|
$27.50
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
ERX214047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Adventist Health Commercial |
$5.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.89
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.62
|
| Rate for Payer: Heritage Provider Network Senior |
$18.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.88
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
|
|
BRIVARACETAM 50 MG TABLET [214047]
|
Facility
OP
|
$27.50
|
|
|
Service Code
|
NDC 50474-570-66
|
| Hospital Charge Code |
ERX214047
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$23.38 |
| Rate for Payer: Adventist Health Commercial |
$5.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.62
|
| Rate for Payer: Blue Shield of California Commercial |
$17.08
|
| Rate for Payer: Blue Shield of California EPN |
$16.14
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.38
|
| Rate for Payer: Dignity Health Senior |
$23.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.02
|
| Rate for Payer: Heritage Provider Network Senior |
$17.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.88
|
| Rate for Payer: Multiplan Commercial |
$20.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.38
|
| Rate for Payer: Vantage Medical Group Senior |
$23.38
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
IP
|
$125.69
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$94.27 |
| Rate for Payer: Adventist Health Commercial |
$25.14
|
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Adventist Health Commercial |
$25.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.35
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.10
|
| Rate for Payer: Heritage Provider Network Senior |
$85.10
|
| Rate for Payer: Heritage Provider Network Senior |
$68.08
|
| Rate for Payer: Heritage Provider Network Senior |
$85.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.42
|
| Rate for Payer: Multiplan Commercial |
$94.27
|
| Rate for Payer: Multiplan Commercial |
$75.42
|
| Rate for Payer: Multiplan Commercial |
$94.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.00
|
|
|
BROMFENAC 0.09 % EYE DROPS [41146]
|
Facility
OP
|
$125.70
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG41146B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$106.84 |
| Rate for Payer: Adventist Health Commercial |
$25.14
|
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Adventist Health Commercial |
$25.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$85.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$106.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$55.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$94.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$75.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$94.28
|
| Rate for Payer: Blue Shield of California Commercial |
$62.45
|
| Rate for Payer: Blue Shield of California Commercial |
$78.05
|
| Rate for Payer: Blue Shield of California Commercial |
$78.06
|
| Rate for Payer: Blue Shield of California EPN |
$73.78
|
| Rate for Payer: Blue Shield of California EPN |
$59.03
|
| Rate for Payer: Blue Shield of California EPN |
$73.79
|
| Rate for Payer: Cash Price |
$56.56
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.84
|
| Rate for Payer: Dignity Health Senior |
$106.84
|
| Rate for Payer: Dignity Health Senior |
$106.84
|
| Rate for Payer: Dignity Health Senior |
$85.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.56
|
| Rate for Payer: Heritage Provider Network Senior |
$58.20
|
| Rate for Payer: Heritage Provider Network Senior |
$58.19
|
| Rate for Payer: Heritage Provider Network Senior |
$46.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.42
|
| Rate for Payer: Multiplan Commercial |
$75.42
|
| Rate for Payer: Multiplan Commercial |
$94.27
|
| Rate for Payer: Multiplan Commercial |
$94.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$106.84
|
| Rate for Payer: Vantage Medical Group Senior |
$85.48
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
IP
|
$6.02
|
|
|
Service Code
|
NDC 0781-5325-31
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Cash Price |
$2.71
|
| 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 |
$4.52
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
IP
|
$3.97
|
|
|
Service Code
|
NDC 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| 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 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 0574-0106-03
|
| Hospital Charge Code |
1710748
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| 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 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 |
$1.91
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.37
|
| Rate for Payer: Vantage Medical Group Senior |
$3.37
|
|
|
BROMOCRIPTINE 2.5 MG TABLET [9297]
|
Facility
OP
|
$3.97
|
|
|
Service Code
|
NDC 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| 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 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 |
$1.91
|
| 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
|
| 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 63304-962-30
|
| Hospital Charge Code |
1710748
|
|
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 |
$2.73
|
| 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 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
|
|
