|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
|
IP
|
$64.21
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$54.58 |
| Rate for Payer: Adventist Health Commercial |
$12.84
|
| Rate for Payer: Blue Shield of California Commercial |
$47.39
|
| Rate for Payer: Blue Shield of California EPN |
$31.21
|
| Rate for Payer: Cash Price |
$35.32
|
| Rate for Payer: Cigna of CA HMO |
$44.95
|
| Rate for Payer: Cigna of CA PPO |
$44.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.68
|
| Rate for Payer: EPIC Health Plan Senior |
$25.68
|
| Rate for Payer: Galaxy Health WC |
$54.58
|
| Rate for Payer: Global Benefits Group Commercial |
$38.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.41
|
| Rate for Payer: Multiplan Commercial |
$51.37
|
| Rate for Payer: Networks By Design Commercial |
$41.74
|
| Rate for Payer: Prime Health Services Commercial |
$54.58
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
|
IP
|
$64.21
|
|
|
Service Code
|
NDC 50242-100-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$54.58 |
| Rate for Payer: Adventist Health Commercial |
$12.84
|
| Rate for Payer: Blue Shield of California Commercial |
$47.39
|
| Rate for Payer: Blue Shield of California EPN |
$31.21
|
| Rate for Payer: Cash Price |
$35.32
|
| Rate for Payer: Cigna of CA HMO |
$44.95
|
| Rate for Payer: Cigna of CA PPO |
$44.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.68
|
| Rate for Payer: EPIC Health Plan Senior |
$25.68
|
| Rate for Payer: Galaxy Health WC |
$54.58
|
| Rate for Payer: Global Benefits Group Commercial |
$38.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.41
|
| Rate for Payer: Multiplan Commercial |
$51.37
|
| Rate for Payer: Networks By Design Commercial |
$41.74
|
| Rate for Payer: Prime Health Services Commercial |
$54.58
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
|
OP
|
$64.21
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$54.58 |
| Rate for Payer: Adventist Health Commercial |
$12.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$42.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.43
|
| Rate for Payer: Cash Price |
$35.32
|
| Rate for Payer: Cigna of CA HMO |
$44.95
|
| Rate for Payer: Cigna of CA PPO |
$44.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$54.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.68
|
| Rate for Payer: EPIC Health Plan Senior |
$25.68
|
| Rate for Payer: Galaxy Health WC |
$54.58
|
| Rate for Payer: Global Benefits Group Commercial |
$38.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.95
|
| Rate for Payer: Multiplan Commercial |
$51.37
|
| Rate for Payer: Networks By Design Commercial |
$41.74
|
| Rate for Payer: Prime Health Services Commercial |
$54.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$38.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$38.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.10
|
| Rate for Payer: United Healthcare All Other HMO |
$32.10
|
| Rate for Payer: United Healthcare HMO Rider |
$32.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$32.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.58
|
| Rate for Payer: Vantage Medical Group Senior |
$54.58
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
|
OP
|
$64.21
|
|
|
Service Code
|
NDC 50242-100-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$54.58 |
| Rate for Payer: Adventist Health Commercial |
$12.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$42.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.43
|
| Rate for Payer: Cash Price |
$35.32
|
| Rate for Payer: Cigna of CA HMO |
$44.95
|
| Rate for Payer: Cigna of CA PPO |
$44.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$54.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.68
|
| Rate for Payer: EPIC Health Plan Senior |
$25.68
|
| Rate for Payer: Galaxy Health WC |
$54.58
|
| Rate for Payer: Global Benefits Group Commercial |
$38.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$42.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.95
|
| Rate for Payer: Multiplan Commercial |
$51.37
|
| Rate for Payer: Networks By Design Commercial |
$41.74
|
| Rate for Payer: Prime Health Services Commercial |
$54.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$38.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$38.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.10
|
| Rate for Payer: United Healthcare All Other HMO |
$32.10
|
| Rate for Payer: United Healthcare HMO Rider |
$32.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$32.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.58
|
| Rate for Payer: Vantage Medical Group Senior |
$54.58
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 42571-147-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.68
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 61314-030-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.47
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.43
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.68
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 42571-147-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.43
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
OP
|
$4.08
|
|
|
Service Code
|
NDC 42571-141-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.51
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna of CA HMO |
$2.86
|
| Rate for Payer: Cigna of CA PPO |
$2.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: EPIC Health Plan Senior |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$3.47
|
| Rate for Payer: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.86
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
| Rate for Payer: Networks By Design Commercial |
$2.65
|
| Rate for Payer: Prime Health Services Commercial |
$3.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.04
|
| Rate for Payer: United Healthcare All Other HMO |
$2.04
|
| Rate for Payer: United Healthcare HMO Rider |
$2.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Vantage Medical Group Senior |
$3.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 61314-019-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
OP
|
$4.08
|
|
|
Service Code
|
NDC 24208-485-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Cigna of CA PPO |
$2.86
|
| Rate for Payer: Cigna of CA HMO |
$2.86
|
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.51
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: EPIC Health Plan Senior |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$3.47
|
| Rate for Payer: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.86
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
| Rate for Payer: Networks By Design Commercial |
$2.65
|
| Rate for Payer: Prime Health Services Commercial |
$3.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.04
|
| Rate for Payer: United Healthcare All Other HMO |
$2.04
|
| Rate for Payer: United Healthcare HMO Rider |
$2.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Vantage Medical Group Senior |
$3.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$4.08
|
|
|
Service Code
|
NDC 24208-485-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$3.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.98
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna of CA HMO |
$2.86
|
| Rate for Payer: Cigna of CA PPO |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: EPIC Health Plan Senior |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$3.47
|
| Rate for Payer: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
| Rate for Payer: Networks By Design Commercial |
$2.65
|
| Rate for Payer: Prime Health Services Commercial |
$3.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 72266-197-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 61314-019-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 72266-197-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.11
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$4.08
|
|
|
Service Code
|
NDC 42571-141-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$3.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.98
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna of CA HMO |
$2.86
|
| Rate for Payer: Cigna of CA PPO |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: EPIC Health Plan Senior |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$3.47
|
| Rate for Payer: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
| Rate for Payer: Networks By Design Commercial |
$2.65
|
| Rate for Payer: Prime Health Services Commercial |
$3.47
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
OP
|
$4.13
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$2.89
|
| Rate for Payer: Cigna of CA PPO |
$2.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: EPIC Health Plan Senior |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.51
|
| Rate for Payer: Global Benefits Group Commercial |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.06
|
| Rate for Payer: United Healthcare HMO Rider |
$2.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: Vantage Medical Group Senior |
$3.51
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$1.90
|
| Rate for Payer: Cigna of CA PPO |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
| Rate for Payer: Networks By Design Commercial |
$1.76
|
| Rate for Payer: Prime Health Services Commercial |
$2.30
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO |
$1.90
|
| Rate for Payer: Cigna of CA PPO |
$1.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
| Rate for Payer: Networks By Design Commercial |
$1.76
|
| Rate for Payer: Prime Health Services Commercial |
$2.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other HMO |
$1.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2.30
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO |
$0.96
|
| Rate for Payer: United Healthcare HMO Rider |
$0.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$4.13
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$2.89
|
| Rate for Payer: Cigna of CA PPO |
$2.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: EPIC Health Plan Senior |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.51
|
| Rate for Payer: Global Benefits Group Commercial |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.51
|
|
