|
DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]
|
Facility
|
OP
|
$315.64
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
ERX2619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$236.73 |
| 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 |
$142.04
|
| 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 Beech St/Commercial/PHCS |
$236.73
|
|
|
DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]
|
Facility
|
IP
|
$315.64
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
ERX2619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$252.51 |
| Rate for Payer: Cash Price |
$142.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$236.73
|
|
|
DOXORUBICIN BEADS (100-300 LC BEADS) [4081299]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
1755775
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
DOXORUBICIN BEADS (100-300 LC BEADS) [4081299]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
1755775
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.89 |
| 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 |
$0.53
|
| 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
DOXORUBICIN BEADS (QUADRASPHERE) [4081287]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
1755775
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
DOXORUBICIN BEADS (QUADRASPHERE) [4081287]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
1755775
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.89 |
| 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 |
$0.53
|
| 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
OP
|
$81.40
|
|
|
Service Code
|
NDC 70710-1530-1
|
| Hospital Charge Code |
1755636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$61.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$48.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$48.84
|
| Rate for Payer: Cash Price |
$36.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$48.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.77
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$61.05
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 43598-283-35
|
| Hospital Charge Code |
1755636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$32.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$40.50
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
NDC 43598-283-35
|
| Hospital Charge Code |
1755636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$32.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$32.40
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$32.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$40.50
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
IP
|
$81.40
|
|
|
Service Code
|
NDC 70710-1530-1
|
| Hospital Charge Code |
1755636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$65.12 |
| Rate for Payer: Cash Price |
$36.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.77
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$61.05
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
OP
|
$80.83
|
|
|
Service Code
|
NDC 0338-0067-01
|
| Hospital Charge Code |
1755794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$60.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$48.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$36.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$48.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$60.62
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
IP
|
$80.83
|
|
|
Service Code
|
NDC 0338-0067-01
|
| Hospital Charge Code |
1755794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$64.66 |
| Rate for Payer: Cash Price |
$36.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$64.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$48.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$60.62
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 43598-541-25
|
| Hospital Charge Code |
1755794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.00
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 43598-541-25
|
| Hospital Charge Code |
1755794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.00
|
| Rate for Payer: Cash Price |
$27.00
|
| 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: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.00
|
|
|
DOXYCYCLINE 10 MG/ML TOPICAL [4081094]
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
NDC 99994-0810-94
|
| Hospital Charge Code |
NDC4081094
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.18
|
|
|
DOXYCYCLINE 10 MG/ML TOPICAL [4081094]
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
NDC 99994-0810-94
|
| Hospital Charge Code |
NDC4081094
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.18 |
| 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 |
$1.31
|
| 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 |
$1.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.18
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
NDC 0143-3142-50
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.08 |
| 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 |
$0.65
|
| 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 Beech St/Commercial/PHCS |
$1.08
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
NDC 0143-3142-50
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.08
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-11
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.51
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0143-9803-50
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0143-9803-50
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
NDC 50268-278-11
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.28
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-65
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.51
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 0069-0950-50
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
NDC 50268-278-11
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.82
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.28
|
|
