|
DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION [108908]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$15.36
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION [196796]
|
Facility
|
OP
|
$25.50
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.03 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.30
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.30
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.15
|
| Rate for Payer: Multiplan Commercial |
$20.66
|
| Rate for Payer: Multiplan Commercial |
$19.12
|
|
|
DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION [196796]
|
Facility
|
IP
|
$27.54
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.15
|
| Rate for Payer: Multiplan Commercial |
$19.12
|
| Rate for Payer: Multiplan Commercial |
$20.66
|
|
|
DOCETAXEL 20 MG/2 ML (10 MG/ML) INTRAVENOUS SOLUTION [108910]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
DOCETAXEL 20 MG/2 ML (10 MG/ML) INTRAVENOUS SOLUTION [108910]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
DOCETAXEL 20 MG/ML (1 ML) INTRAVENOUS SOLUTION [106443]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
DOCETAXEL 20 MG/ML (1 ML) INTRAVENOUS SOLUTION [106443]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108122]
|
Facility
|
OP
|
$27.54
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.52
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$78.30
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$78.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.52
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Cash Price |
$71.78
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$104.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$78.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$78.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.15
|
| Rate for Payer: Multiplan Commercial |
$19.12
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
| Rate for Payer: Multiplan Commercial |
$20.66
|
|
|
DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108122]
|
Facility
|
IP
|
$130.50
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.78 |
| Max. Negotiated Rate |
$104.40 |
| Rate for Payer: Cash Price |
$71.78
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$22.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$104.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$78.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.03
|
| Rate for Payer: Multiplan Commercial |
$20.66
|
| Rate for Payer: Multiplan Commercial |
$19.12
|
| Rate for Payer: Multiplan Commercial |
$97.88
|
|
|
DOCETAXEL 80 MG/8 ML (10 MG/ML) INTRAVENOUS SOLUTION [108907]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.40
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
DOCETAXEL 80 MG/8 ML (10 MG/ML) INTRAVENOUS SOLUTION [108907]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [29287]
|
Facility
|
IP
|
$8.33
|
|
|
Service Code
|
NDC 46122-800-36
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$6.66 |
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$6.25
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [29287]
|
Facility
|
OP
|
$8.33
|
|
|
Service Code
|
NDC 46122-800-36
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$6.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.00
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$6.25
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [29287]
|
Facility
|
IP
|
$8.39
|
|
|
Service Code
|
NDC 46122-681-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.61 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$6.29
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [29287]
|
Facility
|
OP
|
$8.02
|
|
|
Service Code
|
NDC 61269-881-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$4.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$6.01
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [29287]
|
Facility
|
IP
|
$8.02
|
|
|
Service Code
|
NDC 61269-881-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$6.42 |
| Rate for Payer: Cash Price |
$4.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$6.01
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [29287]
|
Facility
|
OP
|
$8.39
|
|
|
Service Code
|
NDC 46122-681-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.61 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.03
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$6.29
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0904-7183-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 46122-692-85
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 60687-129-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 60687-129-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904-7280-80
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0904-7280-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 60687-129-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 46122-692-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
