|
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 |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| 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 |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: Blue Distinction Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$2.70
|
| 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 Media |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.50
|
| 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: 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
|
| 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 |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.04 |
| 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 |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.43
|
| Rate for Payer: Blue Distinction Transplant |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| 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 Media |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.80
|
| 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: 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
|
| 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 50383-233-10
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.70
|
| 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: 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: 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
|
IP
|
$9.10
|
|
|
Service Code
|
NDC 0006-3519-36
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$7.74 |
| Rate for Payer: Blue Shield of California Commercial |
$6.48
|
| Rate for Payer: Blue Shield of California EPN |
$4.66
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$6.37
|
| Rate for Payer: Cigna of CA PPO |
$6.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.64
|
| Rate for Payer: Galaxy Health WC |
$7.74
|
| Rate for Payer: Global Benefits Group Commercial |
$5.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
| Rate for Payer: Networks By Design Commercial |
$5.92
|
| Rate for Payer: Prime Health Services Commercial |
$7.74
|
|
|
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 |
$2.18 |
| Max. Negotiated Rate |
$7.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.42
|
| Rate for Payer: Blue Distinction Transplant |
$5.46
|
| Rate for Payer: Blue Shield of California Commercial |
$6.71
|
| Rate for Payer: Blue Shield of California EPN |
$5.31
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$6.37
|
| Rate for Payer: Cigna of CA PPO |
$6.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.74
|
| Rate for Payer: Dignity Health Media |
$7.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.64
|
| Rate for Payer: Galaxy Health WC |
$7.74
|
| Rate for Payer: Global Benefits Group Commercial |
$5.46
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
| Rate for Payer: Networks By Design Commercial |
$5.92
|
| Rate for Payer: Prime Health Services Commercial |
$7.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Other HMO |
$4.55
|
| Rate for Payer: United Healthcare HMO Rider |
$4.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.74
|
| Rate for Payer: Vantage Medical Group Senior |
$7.74
|
|
|
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 |
$0.98 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$1.84
|
| 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: 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: 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
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 50383-232-10
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: Blue Distinction Transplant |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.45
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Media |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
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 |
$0.98 |
| Max. Negotiated Rate |
$3.47 |
| 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 |
$2.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.43
|
| Rate for Payer: Blue Distinction Transplant |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$3.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$1.84
|
| 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 Media |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$3.47
|
| Rate for Payer: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.06
|
| 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: 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
|
| 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 42571-141-26
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.09
|
| Rate for Payer: Cash Price |
$1.84
|
| 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: 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: 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
|
$4.20
|
|
|
Service Code
|
NDC 50383-232-10
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Blue Shield of California Commercial |
$2.99
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
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 |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: 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: 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
|
$4.08
|
|
|
Service Code
|
NDC 24208-485-10
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$3.47 |
| 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 |
$2.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.43
|
| Rate for Payer: Blue Distinction Transplant |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$3.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$1.84
|
| 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 Media |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.63
|
| Rate for Payer: Galaxy Health WC |
$3.47
|
| Rate for Payer: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.06
|
| 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: 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
|
| 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 |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| 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 |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.79
|
| Rate for Payer: Blue Distinction Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.75
|
| Rate for Payer: Cash Price |
$1.35
|
| 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 Media |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.25
|
| 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: 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
|
| 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-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
OP
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-30
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.28
|
| Rate for Payer: Blue Distinction Transplant |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Cigna of CA HMO |
$2.68
|
| Rate for Payer: Cigna of CA PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.26
|
| Rate for Payer: Dignity Health Media |
$3.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$3.26
|
| Rate for Payer: Global Benefits Group Commercial |
$2.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: Networks By Design Commercial |
$2.49
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.26
|
|
|
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 |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.86
|
| 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: 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: 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
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.96
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Cigna of CA HMO |
$2.68
|
| Rate for Payer: Cigna of CA PPO |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$3.26
|
| Rate for Payer: Global Benefits Group Commercial |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: Networks By Design Commercial |
$2.49
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
|
|
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 |
$0.65 |
| Max. Negotiated Rate |
$2.30 |
| 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 |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.61
|
| Rate for Payer: Blue Distinction Transplant |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.22
|
| 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 Media |
$2.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1.63
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.03
|
| 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: 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
|
| 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 |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.36
|
| 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 50742-323-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| 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 |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: Blue Distinction Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.86
|
| 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 Media |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.44
|
| 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: 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
|
| 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
|
$1.92
|
|
|
Service Code
|
NDC 50742-323-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.86
|
| 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: 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: 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
|
$1.92
|
|
|
Service Code
|
NDC 50742-323-05
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.63 |
| 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 |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: Blue Distinction Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$0.86
|
| 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 Media |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.44
|
| 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: 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
|
| 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
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-15
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.39
|
| Rate for Payer: Cash Price |
$1.22
|
| 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: 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: 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
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.39
|
| Rate for Payer: Cash Price |
$1.22
|
| 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: 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: 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
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.30 |
| 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 |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.61
|
| Rate for Payer: Blue Distinction Transplant |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.22
|
| 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 Media |
$2.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1.63
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.03
|
| 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: 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
|
| 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 |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.36
|
| 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
|
IP
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-30
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.96
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Cigna of CA HMO |
$2.68
|
| Rate for Payer: Cigna of CA PPO |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$3.26
|
| Rate for Payer: Global Benefits Group Commercial |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: Networks By Design Commercial |
$2.49
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
|
|
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 |
$0.92 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.28
|
| Rate for Payer: Blue Distinction Transplant |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Cigna of CA HMO |
$2.68
|
| Rate for Payer: Cigna of CA PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.26
|
| Rate for Payer: Dignity Health Media |
$3.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$3.26
|
| Rate for Payer: Global Benefits Group Commercial |
$2.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: Networks By Design Commercial |
$2.49
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.26
|
|
