|
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 |
$0.26 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$0.93
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.71
|
| Rate for Payer: Prime Health Services Commercial |
$0.93
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
NDC 50268-278-15
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: Blue Distinction Transplant |
$1.82
|
| Rate for Payer: Blue Shield of California Commercial |
$2.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO |
$2.13
|
| Rate for Payer: Cigna of CA PPO |
$2.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Media |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.43
|
| Rate for Payer: Networks By Design Commercial |
$1.98
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 69238-1100-2
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
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 |
$4.23 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Blue Shield of California Commercial |
$12.54
|
| Rate for Payer: Blue Shield of California EPN |
$9.02
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Galaxy Health WC |
$14.97
|
| Rate for Payer: Global Benefits Group Commercial |
$10.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$14.09
|
| Rate for Payer: Networks By Design Commercial |
$11.45
|
| Rate for Payer: Prime Health Services Commercial |
$14.97
|
|
|
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 |
$7.58 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Blue Shield of California Commercial |
$22.50
|
| Rate for Payer: Blue Shield of California EPN |
$16.18
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: Galaxy Health WC |
$26.86
|
| Rate for Payer: Global Benefits Group Commercial |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$25.28
|
| Rate for Payer: Networks By Design Commercial |
$20.54
|
| Rate for Payer: Prime Health Services Commercial |
$26.86
|
|
|
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 |
$7.23 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.95
|
| Rate for Payer: Blue Distinction Transplant |
$18.07
|
| Rate for Payer: Blue Shield of California Commercial |
$22.20
|
| Rate for Payer: Blue Shield of California EPN |
$17.59
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna of CA HMO |
$19.28
|
| Rate for Payer: Cigna of CA PPO |
$22.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.60
|
| Rate for Payer: Dignity Health Media |
$25.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.05
|
| Rate for Payer: Galaxy Health WC |
$25.60
|
| Rate for Payer: Global Benefits Group Commercial |
$18.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$22.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.23
|
| Rate for Payer: Multiplan Commercial |
$24.10
|
| Rate for Payer: Networks By Design Commercial |
$19.58
|
| Rate for Payer: Prime Health Services Commercial |
$25.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.06
|
| Rate for Payer: United Healthcare All Other HMO |
$15.06
|
| Rate for Payer: United Healthcare HMO Rider |
$15.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.60
|
| Rate for Payer: Vantage Medical Group Senior |
$25.60
|
|
|
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 |
$7.23 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Blue Shield of California Commercial |
$21.45
|
| Rate for Payer: Blue Shield of California EPN |
$15.42
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.05
|
| Rate for Payer: Galaxy Health WC |
$25.60
|
| Rate for Payer: Global Benefits Group Commercial |
$18.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.23
|
| Rate for Payer: Multiplan Commercial |
$24.10
|
| Rate for Payer: Networks By Design Commercial |
$19.58
|
| Rate for Payer: Prime Health Services Commercial |
$25.60
|
|
|
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 |
$4.23 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.49
|
| Rate for Payer: Blue Distinction Transplant |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$12.98
|
| Rate for Payer: Blue Shield of California EPN |
$10.28
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO |
$11.27
|
| Rate for Payer: Cigna of CA PPO |
$13.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.97
|
| Rate for Payer: Dignity Health Media |
$14.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.04
|
| Rate for Payer: Galaxy Health WC |
$14.97
|
| Rate for Payer: Global Benefits Group Commercial |
$10.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$13.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$14.09
|
| Rate for Payer: Networks By Design Commercial |
$11.45
|
| Rate for Payer: Prime Health Services Commercial |
$14.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.80
|
| Rate for Payer: United Healthcare All Other HMO |
$8.80
|
| Rate for Payer: United Healthcare HMO Rider |
$8.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.97
|
| Rate for Payer: Vantage Medical Group Senior |
$14.97
|
|
|
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 |
$7.23 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Blue Shield of California Commercial |
$21.45
|
| Rate for Payer: Blue Shield of California EPN |
$15.42
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.05
|
| Rate for Payer: Galaxy Health WC |
$25.60
|
| Rate for Payer: Global Benefits Group Commercial |
$18.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.23
|
| Rate for Payer: Multiplan Commercial |
$24.10
|
| Rate for Payer: Networks By Design Commercial |
$19.58
|
| Rate for Payer: Prime Health Services Commercial |
$25.60
|
|
|
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 |
$7.58 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Blue Shield of California Commercial |
$22.50
|
| Rate for Payer: Blue Shield of California EPN |
$16.18
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: Galaxy Health WC |
$26.86
|
| Rate for Payer: Global Benefits Group Commercial |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$25.28
|
| Rate for Payer: Networks By Design Commercial |
$20.54
|
| Rate for Payer: Prime Health Services Commercial |
$26.86
|
|
|
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 |
$4.23 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.49
|
| Rate for Payer: Blue Distinction Transplant |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$12.98
|
| Rate for Payer: Blue Shield of California EPN |
$10.28
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO |
$11.27
|
| Rate for Payer: Cigna of CA PPO |
$13.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.97
|
| Rate for Payer: Dignity Health Media |
$14.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.04
|
| Rate for Payer: Galaxy Health WC |
$14.97
|
| Rate for Payer: Global Benefits Group Commercial |
$10.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$13.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$14.09
|
| Rate for Payer: Networks By Design Commercial |
$11.45
|
| Rate for Payer: Prime Health Services Commercial |
$14.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.80
|
| Rate for Payer: United Healthcare All Other HMO |
$8.80
|
| Rate for Payer: United Healthcare HMO Rider |
$8.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.97
|
| Rate for Payer: Vantage Medical Group Senior |
$14.97
|
|
|
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 |
$6.96 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Blue Shield of California Commercial |
$20.64
|
| Rate for Payer: Blue Shield of California EPN |
$14.84
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.60
|
| Rate for Payer: Galaxy Health WC |
$24.64
|
| Rate for Payer: Global Benefits Group Commercial |
$17.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.96
|
| Rate for Payer: Multiplan Commercial |
$23.19
|
| Rate for Payer: Networks By Design Commercial |
$18.84
|
| Rate for Payer: Prime Health Services Commercial |
$24.64
|
|
|
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 |
$7.23 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.95
|
| Rate for Payer: Blue Distinction Transplant |
$18.07
|
| Rate for Payer: Blue Shield of California Commercial |
$22.20
|
| Rate for Payer: Blue Shield of California EPN |
$17.59
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna of CA HMO |
$19.28
|
| Rate for Payer: Cigna of CA PPO |
$22.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.60
|
| Rate for Payer: Dignity Health Media |
$25.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.05
|
| Rate for Payer: Galaxy Health WC |
$25.60
|
| Rate for Payer: Global Benefits Group Commercial |
$18.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$22.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.23
|
| Rate for Payer: Multiplan Commercial |
$24.10
|
| Rate for Payer: Networks By Design Commercial |
$19.58
|
| Rate for Payer: Prime Health Services Commercial |
$25.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.06
|
| Rate for Payer: United Healthcare All Other HMO |
$15.06
|
| Rate for Payer: United Healthcare HMO Rider |
$15.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.60
|
| Rate for Payer: Vantage Medical Group Senior |
$25.60
|
|
|
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 |
$7.58 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$20.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.83
|
| Rate for Payer: Blue Distinction Transplant |
$18.96
|
| Rate for Payer: Blue Shield of California Commercial |
$23.29
|
| Rate for Payer: Blue Shield of California EPN |
$18.45
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO |
$20.22
|
| Rate for Payer: Cigna of CA PPO |
$23.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.86
|
| Rate for Payer: Dignity Health Media |
$26.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.64
|
| Rate for Payer: Galaxy Health WC |
$26.86
|
| Rate for Payer: Global Benefits Group Commercial |
$18.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$23.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$25.28
|
| Rate for Payer: Networks By Design Commercial |
$20.54
|
| Rate for Payer: Prime Health Services Commercial |
$26.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.80
|
| Rate for Payer: United Healthcare All Other HMO |
$15.80
|
| Rate for Payer: United Healthcare HMO Rider |
$15.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.86
|
| Rate for Payer: Vantage Medical Group Senior |
$26.86
|
|
|
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 |
$7.58 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$20.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.83
|
| Rate for Payer: Blue Distinction Transplant |
$18.96
|
| Rate for Payer: Blue Shield of California Commercial |
$23.29
|
| Rate for Payer: Blue Shield of California EPN |
$18.45
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO |
$20.22
|
| Rate for Payer: Cigna of CA PPO |
$23.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.86
|
| Rate for Payer: Dignity Health Media |
$26.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.64
|
| Rate for Payer: Galaxy Health WC |
$26.86
|
| Rate for Payer: Global Benefits Group Commercial |
$18.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$23.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$25.28
|
| Rate for Payer: Networks By Design Commercial |
$20.54
|
| Rate for Payer: Prime Health Services Commercial |
$26.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.80
|
| Rate for Payer: United Healthcare All Other HMO |
$15.80
|
| Rate for Payer: United Healthcare HMO Rider |
$15.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.86
|
| Rate for Payer: Vantage Medical Group Senior |
$26.86
|
|
|
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 |
$6.96 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.27
|
| Rate for Payer: Blue Distinction Transplant |
$17.39
|
| Rate for Payer: Blue Shield of California Commercial |
$21.37
|
| Rate for Payer: Blue Shield of California EPN |
$16.93
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna of CA HMO |
$18.55
|
| Rate for Payer: Cigna of CA PPO |
$21.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.64
|
| Rate for Payer: Dignity Health Media |
$24.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.60
|
| Rate for Payer: Galaxy Health WC |
$24.64
|
| Rate for Payer: Global Benefits Group Commercial |
$17.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$21.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.96
|
| Rate for Payer: Multiplan Commercial |
$23.19
|
| Rate for Payer: Networks By Design Commercial |
$18.84
|
| Rate for Payer: Prime Health Services Commercial |
$24.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.50
|
| Rate for Payer: United Healthcare All Other HMO |
$14.50
|
| Rate for Payer: United Healthcare HMO Rider |
$14.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.64
|
| Rate for Payer: Vantage Medical Group Senior |
$24.64
|
|
|
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 |
$6.96 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Blue Shield of California Commercial |
$20.64
|
| Rate for Payer: Blue Shield of California EPN |
$14.84
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.60
|
| Rate for Payer: Galaxy Health WC |
$24.64
|
| Rate for Payer: Global Benefits Group Commercial |
$17.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.96
|
| Rate for Payer: Multiplan Commercial |
$23.19
|
| Rate for Payer: Networks By Design Commercial |
$18.84
|
| Rate for Payer: Prime Health Services Commercial |
$24.64
|
|
|
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 |
$4.23 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Blue Shield of California Commercial |
$12.54
|
| Rate for Payer: Blue Shield of California EPN |
$9.02
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Galaxy Health WC |
$14.97
|
| Rate for Payer: Global Benefits Group Commercial |
$10.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$14.09
|
| Rate for Payer: Networks By Design Commercial |
$11.45
|
| Rate for Payer: Prime Health Services Commercial |
$14.97
|
|
|
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 |
$6.96 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.27
|
| Rate for Payer: Blue Distinction Transplant |
$17.39
|
| Rate for Payer: Blue Shield of California Commercial |
$21.37
|
| Rate for Payer: Blue Shield of California EPN |
$16.93
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna of CA HMO |
$18.55
|
| Rate for Payer: Cigna of CA PPO |
$21.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.64
|
| Rate for Payer: Dignity Health Media |
$24.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.60
|
| Rate for Payer: Galaxy Health WC |
$24.64
|
| Rate for Payer: Global Benefits Group Commercial |
$17.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$21.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.96
|
| Rate for Payer: Multiplan Commercial |
$23.19
|
| Rate for Payer: Networks By Design Commercial |
$18.84
|
| Rate for Payer: Prime Health Services Commercial |
$24.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.50
|
| Rate for Payer: United Healthcare All Other HMO |
$14.50
|
| Rate for Payer: United Healthcare HMO Rider |
$14.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.64
|
| Rate for Payer: Vantage Medical Group Senior |
$24.64
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$20.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.83
|
| Rate for Payer: Blue Distinction Transplant |
$18.96
|
| Rate for Payer: Blue Shield of California Commercial |
$23.29
|
| Rate for Payer: Blue Shield of California EPN |
$18.45
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO |
$20.22
|
| Rate for Payer: Cigna of CA PPO |
$23.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.86
|
| Rate for Payer: Dignity Health Media |
$26.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.64
|
| Rate for Payer: Galaxy Health WC |
$26.86
|
| Rate for Payer: Global Benefits Group Commercial |
$18.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$23.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$25.28
|
| Rate for Payer: Networks By Design Commercial |
$20.54
|
| Rate for Payer: Prime Health Services Commercial |
$26.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.80
|
| Rate for Payer: United Healthcare All Other HMO |
$15.80
|
| Rate for Payer: United Healthcare HMO Rider |
$15.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.86
|
| Rate for Payer: Vantage Medical Group Senior |
$26.86
|
|
|
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 |
$6.05 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.01
|
| Rate for Payer: Blue Distinction Transplant |
$15.12
|
| Rate for Payer: Blue Shield of California Commercial |
$18.57
|
| Rate for Payer: Blue Shield of California EPN |
$14.72
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: Cigna of CA HMO |
$16.13
|
| Rate for Payer: Cigna of CA PPO |
$18.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.42
|
| Rate for Payer: Dignity Health Media |
$21.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.08
|
| Rate for Payer: Galaxy Health WC |
$21.42
|
| Rate for Payer: Global Benefits Group Commercial |
$15.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$18.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$20.16
|
| Rate for Payer: Networks By Design Commercial |
$16.38
|
| Rate for Payer: Prime Health Services Commercial |
$21.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.60
|
| Rate for Payer: United Healthcare All Other HMO |
$12.60
|
| Rate for Payer: United Healthcare HMO Rider |
$12.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.42
|
| Rate for Payer: Vantage Medical Group Senior |
$21.42
|
|
|
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 |
$6.05 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Blue Shield of California Commercial |
$17.94
|
| Rate for Payer: Blue Shield of California EPN |
$12.90
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.08
|
| Rate for Payer: Galaxy Health WC |
$21.42
|
| Rate for Payer: Global Benefits Group Commercial |
$15.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$20.16
|
| Rate for Payer: Networks By Design Commercial |
$16.38
|
| Rate for Payer: Prime Health Services Commercial |
$21.42
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-11
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Blue Shield of California Commercial |
$22.50
|
| Rate for Payer: Blue Shield of California EPN |
$16.18
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: Galaxy Health WC |
$26.86
|
| Rate for Payer: Global Benefits Group Commercial |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$25.28
|
| Rate for Payer: Networks By Design Commercial |
$20.54
|
| Rate for Payer: Prime Health Services Commercial |
$26.86
|
|
