|
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 |
$0.49 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.86
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$3.83
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.63
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Senior |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
|
|
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 |
$0.49 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.86
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
|
|
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 |
$0.69 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.63
|
| 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 |
$2.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.26
|
| Rate for Payer: Dignity Health Senior |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.53
|
| Rate for Payer: TriValley Medical Group Senior |
$1.53
|
| 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
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-15
|
| Hospital Charge Code |
ERX191035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.30
|
| Rate for Payer: Dignity Health Senior |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.68
|
| Rate for Payer: Heritage Provider Network Senior |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Senior |
$1.08
|
| 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 |
$241.40 |
| Max. Negotiated Rate |
$1,000.27 |
| Rate for Payer: Adventist Health Commercial |
$266.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$916.25
|
| Rate for Payer: Cash Price |
$600.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$613.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$720.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$902.91
|
| Rate for Payer: Heritage Provider Network Senior |
$902.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$241.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$333.42
|
| Rate for Payer: Multiplan Commercial |
$1,000.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$486.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$445.59
|
|
|
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 |
$220.07 |
| Max. Negotiated Rate |
$1,000.27 |
| Rate for Payer: Adventist Health Commercial |
$266.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$573.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$916.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$256.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$256.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$443.25
|
| Rate for Payer: Blue Shield of California Commercial |
$220.07
|
| Rate for Payer: Blue Shield of California EPN |
$220.07
|
| Rate for Payer: Cash Price |
$600.16
|
| Rate for Payer: Cash Price |
$600.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$613.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$256.58
|
| Rate for Payer: Dignity Health Senior |
$256.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$853.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$233.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$617.50
|
| Rate for Payer: Heritage Provider Network Senior |
$617.50
|
| Rate for Payer: Humana Medicare |
$233.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$370.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$233.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$443.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$241.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$333.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$293.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$293.91
|
| Rate for Payer: Multiplan Commercial |
$1,000.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$533.48
|
| Rate for Payer: TriValley Medical Group Senior |
$533.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$486.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$445.59
|
| 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
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 68084-836-01
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0093-0
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 68084-836-11
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 68084-836-95
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 68084-836-25
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 68084-836-11
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0093-0
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 68084-836-25
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 68084-836-01
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 68084-836-95
|
| Hospital Charge Code |
1711544
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
DOXAZOSIN 2 MG TABLET [9895]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 68084-851-95
|
| Hospital Charge Code |
1712210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
DOXAZOSIN 2 MG TABLET [9895]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0094-0
|
| Hospital Charge Code |
1712210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
DOXAZOSIN 2 MG TABLET [9895]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 68084-851-25
|
| Hospital Charge Code |
1712210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
DOXAZOSIN 2 MG TABLET [9895]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 68084-851-25
|
| Hospital Charge Code |
1712210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
DOXAZOSIN 2 MG TABLET [9895]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0094-0
|
| Hospital Charge Code |
1712210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
DOXAZOSIN 2 MG TABLET [9895]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 68084-851-95
|
| Hospital Charge Code |
1712210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
DOXAZOSIN 4 MG TABLET [9896]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 16729-213-01
|
| Hospital Charge Code |
1712422
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
DOXAZOSIN 4 MG TABLET [9896]
|
Facility
|
IP
|
$1.03
|
|
|
Service Code
|
NDC 68084-862-95
|
| Hospital Charge Code |
1712422
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
