|
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 |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| 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: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| 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 24208-485-10
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.48
|
| 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 Exchange |
$1.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.41
|
| Rate for Payer: BCBS Transplant Transplant |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$2.57
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Central Health Plan Commercial |
$3.26
|
| 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: 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 Management Network EPO/PPO |
$3.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.06
|
| Rate for Payer: IEHP medi-cal |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| 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: Riverside University Health MISP |
$1.63
|
| 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 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 |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| 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 Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.77
|
| Rate for Payer: BCBS Transplant Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| 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: 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 Management Network EPO/PPO |
$2.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.25
|
| Rate for Payer: IEHP medi-cal |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| 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: Riverside University Health MISP |
$1.20
|
| 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 Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
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 |
$1.82 |
| Max. Negotiated Rate |
$8.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.53
|
| 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 Exchange |
$4.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.38
|
| Rate for Payer: BCBS Transplant Transplant |
$5.46
|
| Rate for Payer: Blue Shield of California Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California EPN |
$4.45
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Central Health Plan Commercial |
$7.28
|
| 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: 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 Management Network EPO/PPO |
$8.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.82
|
| Rate for Payer: IEHP medi-cal |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$6.82
|
| 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: Riverside University Health MISP |
$3.64
|
| 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 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 |
$0.82 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Central Health Plan Commercial |
$3.26
|
| 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: Health Management Network EPO/PPO |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| 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
|
$9.10
|
|
|
Service Code
|
NDC 0006-3519-36
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$8.19 |
| Rate for Payer: Blue Shield of California Commercial |
$6.82
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Central Health Plan Commercial |
$7.28
|
| 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: Health Management Network EPO/PPO |
$8.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$6.82
|
| 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
|
$4.08
|
|
|
Service Code
|
NDC 42571-141-26
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.48
|
| 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 Exchange |
$1.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.41
|
| Rate for Payer: BCBS Transplant Transplant |
$2.45
|
| Rate for Payer: Blue Shield of California Commercial |
$2.57
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Central Health Plan Commercial |
$3.26
|
| 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: 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 Management Network EPO/PPO |
$3.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.06
|
| Rate for Payer: IEHP medi-cal |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| 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: Riverside University Health MISP |
$1.63
|
| 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 Medi-Cal |
$3.47
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.55
|
| 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 Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.48
|
| Rate for Payer: BCBS Transplant Transplant |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| 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: 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 Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.15
|
| Rate for Payer: IEHP medi-cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| 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: Riverside University Health MISP |
$1.68
|
| 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 Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Blue Shield of California Commercial |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| 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: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
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 |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Blue Shield of California Commercial |
$3.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| 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: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| 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
|
$4.08
|
|
|
Service Code
|
NDC 42571-141-26
|
| Hospital Charge Code |
1740298
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Central Health Plan Commercial |
$3.26
|
| 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: Health Management Network EPO/PPO |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| 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
IP
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-30
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Blue Shield of California Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Central Health Plan Commercial |
$3.06
|
| 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: Health Management Network EPO/PPO |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| 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
IP
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.45
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Central Health Plan Commercial |
$2.17
|
| 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: Health Management Network EPO/PPO |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
| 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
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-30
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.26
|
| Rate for Payer: BCBS Transplant Transplant |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Central Health Plan Commercial |
$3.06
|
| 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: 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 Management Network EPO/PPO |
$3.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.87
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.49
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.30
|
| Rate for Payer: Riverside University Health MISP |
$1.53
|
| 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 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 |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| 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 50742-323-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: 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 Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| Rate for Payer: IEHP medi-cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: Riverside University Health MISP |
$0.77
|
| 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 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
OP
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.26
|
| Rate for Payer: BCBS Transplant Transplant |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Central Health Plan Commercial |
$3.06
|
| 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: 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 Management Network EPO/PPO |
$3.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.87
|
| Rate for Payer: IEHP medi-cal |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.49
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.30
|
| Rate for Payer: Riverside University Health MISP |
$1.53
|
| 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 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
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-15
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.45
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Central Health Plan Commercial |
$2.17
|
| 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: Health Management Network EPO/PPO |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
| 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 50742-323-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| 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 |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: 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 Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| Rate for Payer: IEHP medi-cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: Riverside University Health MISP |
$0.77
|
| 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 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
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Blue Shield of California Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Central Health Plan Commercial |
$3.06
|
| 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: Health Management Network EPO/PPO |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| 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 65862-947-60
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.60
|
| Rate for Payer: BCBS Transplant Transplant |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Central Health Plan Commercial |
$2.17
|
| 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: 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 Management Network EPO/PPO |
$2.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.03
|
| Rate for Payer: IEHP medi-cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
| Rate for Payer: Networks By Design Commercial |
$1.76
|
| Rate for Payer: Prime Health Services Commercial |
$2.30
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.63
|
| Rate for Payer: Riverside University Health MISP |
$1.08
|
| 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 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
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-15
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.60
|
| Rate for Payer: BCBS Transplant Transplant |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Central Health Plan Commercial |
$2.17
|
| 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: 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 Management Network EPO/PPO |
$2.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.03
|
| Rate for Payer: IEHP medi-cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
| Rate for Payer: Networks By Design Commercial |
$1.76
|
| Rate for Payer: Prime Health Services Commercial |
$2.30
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.63
|
| Rate for Payer: Riverside University Health MISP |
$1.08
|
| 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 Medi-Cal |
$2.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2.30
|
|
|
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [231227]
|
Facility
IP
|
$1,333.69
|
|
|
Service Code
|
CPT J9272
|
| Hospital Charge Code |
NDG231227
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$266.74 |
| Max. Negotiated Rate |
$1,200.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1,000.27
|
| Rate for Payer: Blue Shield of California EPN |
$712.19
|
| Rate for Payer: Cash Price |
$600.16
|
| Rate for Payer: Central Health Plan Commercial |
$1,066.95
|
| Rate for Payer: Cigna of CA HMO |
$933.58
|
| Rate for Payer: Cigna of CA PPO |
$933.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$533.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$533.48
|
| Rate for Payer: Galaxy Health WC |
$1,133.64
|
| Rate for Payer: Global Benefits Group Commercial |
$800.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,200.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$889.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$266.74
|
| Rate for Payer: Multiplan Commercial |
$1,000.27
|
| Rate for Payer: Networks By Design Commercial |
$666.84
|
| Rate for Payer: Prime Health Services Commercial |
$1,133.64
|
|
|
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [231227]
|
Facility
OP
|
$1,333.69
|
|
|
Service Code
|
CPT J9272
|
| Hospital Charge Code |
NDG231227
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.26 |
| Max. Negotiated Rate |
$1,445.51 |
| Rate for Payer: Adventist Health Medi-Cal |
$233.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,445.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$291.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$256.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$256.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$410.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$449.43
|
| Rate for Payer: BCBS Transplant Transplant |
$800.21
|
| Rate for Payer: Blue Shield of California Commercial |
$838.89
|
| Rate for Payer: Blue Shield of California EPN |
$652.17
|
| Rate for Payer: Caremore Medicare Advantage |
$233.26
|
| Rate for Payer: Cash Price |
$600.16
|
| Rate for Payer: Cash Price |
$600.16
|
| Rate for Payer: Central Health Plan Commercial |
$1,066.95
|
| Rate for Payer: Cigna of CA HMO |
$933.58
|
| Rate for Payer: Cigna of CA PPO |
$933.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$314.90
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$233.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$233.26
|
| Rate for Payer: Galaxy Health WC |
$1,133.64
|
| Rate for Payer: Global Benefits Group Commercial |
$800.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,200.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,000.27
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$382.54
|
| Rate for Payer: IEHP medi-cal |
$384.88
|
| Rate for Payer: IEHP Medicare Advantage |
$233.26
|
| Rate for Payer: Innovage PACE Commercial |
$349.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$889.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$233.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$266.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$312.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$312.57
|
| Rate for Payer: Multiplan Commercial |
$1,000.27
|
| Rate for Payer: Networks By Design Commercial |
$666.84
|
| Rate for Payer: Prime Health Services Commercial |
$1,133.64
|
| Rate for Payer: Prime Health Services Medicare |
$247.25
|
| Rate for Payer: Riverside University Health MISP |
$256.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$800.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$800.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$666.84
|
| Rate for Payer: United Healthcare All Other HMO |
$666.84
|
| Rate for Payer: United Healthcare HMO Rider |
$666.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$666.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$256.58
|
| Rate for Payer: Vantage Medical Group Senior |
$256.58
|
|
