|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 51079-437-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 27241-168-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 69238-1170-9
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 27241-168-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 51079-437-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 51079-437-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [120047]
|
Facility
|
IP
|
$2.44
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
|
|
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [120047]
|
Facility
|
OP
|
$2.44
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.46
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION [120048]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION [120048]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.44
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.46
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
|
|
DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION (100 ML) [2616]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
|
|
DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION (100 ML) [2616]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
|
|
DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [120046]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.86
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [120046]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
|
|
DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]
|
Facility
|
IP
|
$315.64
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$252.51 |
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$252.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$189.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.60
|
| Rate for Payer: Multiplan Commercial |
$236.73
|
|
|
DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]
|
Facility
|
OP
|
$315.64
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$252.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$189.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$189.38
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$252.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$189.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$189.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.60
|
| Rate for Payer: Multiplan Commercial |
$236.73
|
|
|
DOXORUBICIN BEADS (100-300 LC BEADS) [4081299]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
DOXORUBICIN BEADS (100-300 LC BEADS) [4081299]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
DOXORUBICIN BEADS (QUADRASPHERE) [4081287]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
DOXORUBICIN BEADS (QUADRASPHERE) [4081287]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cash Price |
$33.13
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$43.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$64.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$32.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$60.62
|
| Rate for Payer: Multiplan Commercial |
$45.17
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$40.50
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$32.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$48.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$48.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$32.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.14
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cash Price |
$33.13
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$43.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$48.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$64.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$32.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$32.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$48.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.46
|
| Rate for Payer: Multiplan Commercial |
$45.17
|
| Rate for Payer: Multiplan Commercial |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$60.62
|
|
|
DOXYCYCLINE 10 MG/ML TOPICAL [4081094]
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
NDC 99994-0810-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.74
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
|
DOXYCYCLINE 10 MG/ML TOPICAL [4081094]
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
NDC 99994-0810-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 50268-278-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
