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All Charges

Charge

Type

Setting

Price

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

OP

$6.00

Service Code	NDC 24208-486-10
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

IP

$6.00

Service Code	NDC 50383-233-10
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

IP

$6.00

Service Code	NDC 24208-486-10
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

IP

$2.40

Service Code	NDC 61314-030-02
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

OP

$6.00

Service Code	NDC 50383-233-10
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

OP

$3.00

Service Code	NDC 61314-019-10
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

OP

$4.20

Service Code	NDC 50383-232-10
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$1.89
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.15

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

IP

$4.20

Service Code	NDC 50383-232-10
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$1.89
Rate for Payer: Cigna of CA HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.15

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

IP

$4.08

Service Code	NDC 42571-141-26
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.26
Rate for Payer: Cash Price	$1.84
Rate for Payer: Cigna of CA HMO/PPO	$3.26
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.06

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

OP

$4.08

Service Code	NDC 42571-141-26
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.45
Rate for Payer: Aetna of CA Government/Medicare	$2.45
Rate for Payer: Cash Price	$1.84
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.06

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

IP

$3.00

Service Code	NDC 61314-019-10
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

IP

$4.08

Service Code	NDC 24208-485-10
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.26
Rate for Payer: Cash Price	$1.84
Rate for Payer: Cigna of CA HMO/PPO	$3.26
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.06

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

IP

$9.10

Service Code	NDC 0006-3519-36
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$7.28
Rate for Payer: Cash Price	$4.10
Rate for Payer: Cigna of CA HMO/PPO	$7.28
Rate for Payer: Health Smart Auto/Commercial	$5.46
Rate for Payer: LLUH Dept of Risk Management WC	$5.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.82

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

OP

$9.10

Service Code	NDC 0006-3519-36
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$6.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.46
Rate for Payer: Aetna of CA Government/Medicare	$5.46
Rate for Payer: Cash Price	$4.10
Rate for Payer: Health Smart Auto/Commercial	$5.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.46
Rate for Payer: LLUH Dept of Risk Management WC	$5.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.82

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

OP

$4.08

Service Code	NDC 24208-485-10
Hospital Charge Code	1740298
Hospital Revenue Code	259
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.45
Rate for Payer: Aetna of CA Government/Medicare	$2.45
Rate for Payer: Cash Price	$1.84
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.06

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

IP

$2.71

Service Code	NDC 65862-947-15
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.17
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.17
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

OP

$1.92

Service Code	NDC 50742-323-05
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

IP

$3.83

Service Code	NDC 82584-604-30
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$1.72
Rate for Payer: Cigna of CA HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.87

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

OP

$3.83

Service Code	NDC 82584-604-01
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$2.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Cash Price	$1.72
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.87

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

IP

$1.92

Service Code	NDC 50742-323-05
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

IP

$1.92

Service Code	NDC 50742-323-60
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

IP

$2.71

Service Code	NDC 65862-947-60
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.17
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.17
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

OP

$2.71

Service Code	NDC 65862-947-15
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.63
Rate for Payer: Aetna of CA Government/Medicare	$1.63
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

IP

$3.83

Service Code	NDC 82584-604-01
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$1.72
Rate for Payer: Cigna of CA HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.87

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

OP

$2.71

Service Code	NDC 65862-947-60
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.63
Rate for Payer: Aetna of CA Government/Medicare	$1.63
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.03

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