|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 68084-743-33
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.34
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 68382-707-18
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 60687-716-21
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.77
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.77
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.96
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [110910]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 23155-135-25
|
| Hospital Charge Code |
1712560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [110910]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 23155-135-25
|
| Hospital Charge Code |
1712560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9901]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 50268-280-11
|
| Hospital Charge Code |
ERX9901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9901]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 50268-280-11
|
| Hospital Charge Code |
ERX9901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE [186780]
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 55494-100-10
|
| Hospital Charge Code |
ERX186780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.92
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.90
|
|
|
DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE [186780]
|
Facility
|
IP
|
$6.53
|
|
|
Service Code
|
NDC 55494-100-10
|
| Hospital Charge Code |
ERX186780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.90
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 4116700607
|
| Hospital Charge Code |
1712323
|
|
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
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 24385-441-64
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 24385-441-64
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 4116700607
|
| Hospital Charge Code |
1712323
|
|
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
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET [14847]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
1712323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT [92074]
|
Facility
|
OP
|
$122.91
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
1720996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$92.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$73.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$73.75
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$73.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$73.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$92.18
|
|
|
DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT [92074]
|
Facility
|
IP
|
$122.91
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
1720996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$98.33 |
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$98.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$73.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$92.18
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-01
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.71
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-11
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 67877-753-60
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| 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 |
$1.52
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-01
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 67877-753-60
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.52 |
| 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 |
$0.91
|
| 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 |
$1.52
|
|
|
DRONABINOL 2.5 MG CAPSULE [9904]
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 60687-375-11
|
| Hospital Charge Code |
1730003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.71
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
OP
|
$11.77
|
|
|
Service Code
|
NDC 60687-386-21
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.06
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.83
|
|
|
DRONABINOL 5 MG CAPSULE [9905]
|
Facility
|
OP
|
$11.77
|
|
|
Service Code
|
NDC 60687-386-11
|
| Hospital Charge Code |
1730005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.06
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$8.83
|
|
