|
DOCUSATE SODIUM 100 MG CAPSULE [2566]
|
Facility
|
IP
|
$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: 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
|
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
|
$0.22
|
|
|
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
|
$0.03
|
|
|
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: 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: LLUH Dept of Risk Management WC |
$0.02
|
| 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
|
$0.09
|
|
|
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: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 50268-268-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0904-7281-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 50268-268-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 46122-693-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 50268-268-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 50268-268-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DOCUSATE SODIUM 250 MG CAPSULE [2567]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0904-7281-60
|
| 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 250 MG CAPSULE [2567]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 46122-693-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 17433-9876-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 17433-9876-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 17433-9876-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 17433-9876-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 17433-9876-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 17433-9876-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
DOCUSATE SODIUM 283 MG ENEMA [12887]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
NDC 17433-9878-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
|
|
DOCUSATE SODIUM 283 MG ENEMA [12887]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
NDC 17433-9878-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.35
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7279-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 9993-6962-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7279-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
