|
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
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-11
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$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 69238-1100-2
|
| 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
|
$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
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-65
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$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
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 0069-0950-50
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$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 INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$30.12
|
|
|
Service Code
|
NDC 66794-237-41
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.59
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-11
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$23.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.96
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.70
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-01
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$23.19 |
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.74
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-11
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$25.28 |
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.70
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-01
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.39
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.74
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$30.12
|
|
|
Service Code
|
NDC 66794-237-41
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.07
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.59
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-10
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$23.19 |
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.74
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$30.12
|
|
|
Service Code
|
NDC 66794-237-02
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.59
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-02
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$23.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.96
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.70
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$17.61
|
|
|
Service Code
|
NDC 72266-237-01
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$14.09 |
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$17.61
|
|
|
Service Code
|
NDC 72266-237-05
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$14.09 |
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$17.61
|
|
|
Service Code
|
NDC 72266-237-05
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.57
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$30.12
|
|
|
Service Code
|
NDC 66794-237-02
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.07
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.57
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.59
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-02
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$25.28 |
| Rate for Payer: Cigna of CA HMO/PPO |
$25.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.96
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.70
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-10
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.39
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.94
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.74
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$17.61
|
|
|
Service Code
|
NDC 72266-237-01
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.57
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]
|
Facility
|
IP
|
$25.20
|
|
|
Service Code
|
NDC 63323-130-17
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$20.16 |
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.90
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]
|
Facility
|
OP
|
$25.20
|
|
|
Service Code
|
NDC 63323-130-17
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$18.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.12
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.90
|
|
