|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
IP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$51.45 |
| Rate for Payer: Blue Shield of California Commercial |
$43.10
|
| Rate for Payer: Blue Shield of California EPN |
$30.99
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Cigna of CA HMO |
$42.37
|
| Rate for Payer: Cigna of CA PPO |
$42.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.21
|
| Rate for Payer: Galaxy Health WC |
$51.45
|
| Rate for Payer: Global Benefits Group Commercial |
$36.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.53
|
| Rate for Payer: Multiplan Commercial |
$48.42
|
| Rate for Payer: Networks By Design Commercial |
$39.34
|
| Rate for Payer: Prime Health Services Commercial |
$51.45
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$74,132.40
|
|
|
Service Code
|
APR-DRG 3043
|
| Min. Negotiated Rate |
$56,867.35 |
| Max. Negotiated Rate |
$74,132.40 |
| Rate for Payer: IEHP Medi-Cal |
$56,867.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74,132.40
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$44,242.51
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$33,938.66 |
| Max. Negotiated Rate |
$44,242.51 |
| Rate for Payer: IEHP Medi-Cal |
$33,938.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44,242.51
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$109,697.37
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$84,149.43 |
| Max. Negotiated Rate |
$109,697.37 |
| Rate for Payer: IEHP Medi-Cal |
$84,149.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109,697.37
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$52,558.26
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$40,317.71 |
| Max. Negotiated Rate |
$52,558.26 |
| Rate for Payer: IEHP Medi-Cal |
$40,317.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52,558.26
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$65,458.40
|
|
|
Service Code
|
APR-DRG 3031
|
| Min. Negotiated Rate |
$50,213.48 |
| Max. Negotiated Rate |
$65,458.40 |
| Rate for Payer: IEHP Medi-Cal |
$50,213.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65,458.40
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$78,621.03
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$60,310.61 |
| Max. Negotiated Rate |
$78,621.03 |
| Rate for Payer: IEHP Medi-Cal |
$60,310.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78,621.03
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$108,212.98
|
|
|
Service Code
|
APR-DRG 3033
|
| Min. Negotiated Rate |
$83,010.75 |
| Max. Negotiated Rate |
$108,212.98 |
| Rate for Payer: IEHP Medi-Cal |
$83,010.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108,212.98
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$142,919.60
|
|
|
Service Code
|
APR-DRG 3034
|
| Min. Negotiated Rate |
$109,634.37 |
| Max. Negotiated Rate |
$142,919.60 |
| Rate for Payer: IEHP Medi-Cal |
$109,634.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142,919.60
|
|
|
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 |
$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 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 42571-147-26
|
| 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 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: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.43
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.44
|
| 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
OP
|
$6.00
|
|
|
Service Code
|
NDC 42571-147-26
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| 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
|
$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: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| 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
|
$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: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| 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: EPIC Health Plan Commercial |
$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: 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 |
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: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| 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 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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$2.52
|
| 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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$7.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.42
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$5.46
|
| 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
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: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.79
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.80
|
| 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
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
|
$4.08
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.43
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$2.45
|
| 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
|
$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: Galaxy Health WC |
$3.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.43
|
| Rate for Payer: BCBS Transplant 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: Global Benefits Group Commercial |
$2.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$2.45
|
| 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
|
$4.20
|
|
|
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
|
|
