|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
OP
|
$4.08
|
|
|
Service Code
|
NDC 42571-141-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: Dignity Health Senior |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Senior |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.86
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: Dignity Health Senior |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Senior |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.86
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$1.80
|
|
|
Service Code
|
NDC 72266-197-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 72266-197-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 61314-019-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 42571-141-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Senior |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 61314-019-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
DORZOLAMIDE 2 % EYE DROPS [14471]
|
Facility
|
IP
|
$4.08
|
|
|
Service Code
|
NDC 24208-485-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Senior |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$4.13
|
|
|
Service Code
|
NDC 82584-604-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.80
|
| Rate for Payer: Heritage Provider Network Senior |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.10
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| 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 |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.49
|
| 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 |
$1.29
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.90
|
| 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: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2.30
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-15
|
| Hospital Charge Code |
901700029
|
|
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 |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.49
|
| 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 |
$1.29
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.90
|
| 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: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2.30
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
OP
|
$4.13
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.10
|
| Rate for Payer: Blue Shield of California Commercial |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.51
|
| Rate for Payer: Dignity Health Senior |
$3.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Senior |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$3.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Senior |
$1.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: Vantage Medical Group Senior |
$3.51
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 50742-323-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 50742-323-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 50742-323-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$4.13
|
|
|
Service Code
|
NDC 82584-604-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.80
|
| Rate for Payer: Heritage Provider Network Senior |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.10
|
|
|
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 |
901700029
|
|
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: Cash Price |
$1.49
|
| 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
|
$4.13
|
|
|
Service Code
|
NDC 82584-604-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.10
|
| Rate for Payer: Blue Shield of California Commercial |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.51
|
| Rate for Payer: Dignity Health Senior |
$3.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Senior |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$3.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Senior |
$1.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: Vantage Medical Group Senior |
$3.51
|
|
|
DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]
|
Facility
|
IP
|
$2.71
|
|
|
Service Code
|
NDC 65862-947-15
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$1.49
|
| 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
|
|
|
DOXAPRAM 20 MG/ML INTRAVENOUS SOLUTION [2607]
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 0641-6018-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.71
|
| Rate for Payer: Dignity Health Senior |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$2.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.71
|
| Rate for Payer: Vantage Medical Group Senior |
$2.71
|
|
|
DOXAPRAM 20 MG/ML INTRAVENOUS SOLUTION [2607]
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 0641-6018-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Senior |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.39
|
|
|
DOXAZOSIN 1 MG TABLET [9894]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0093-0
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| 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 |
$0.24
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| 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: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| 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 |
901700029
|
|
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 |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.60
|
| 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 |
$0.52
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.76
|
| 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: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.93
|
| 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
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 68084-836-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
