|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
NDC 50268-278-15
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
|
|
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 |
$0.55 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.55 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| 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 |
$2.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| 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
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-11
|
| Hospital Charge Code |
1711312
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
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 |
$0.36 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Senior |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
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 |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
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 |
$3.19 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Adventist Health Commercial |
$3.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.10
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.92
|
| Rate for Payer: Heritage Provider Network Senior |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.40
|
| Rate for Payer: Multiplan Commercial |
$13.21
|
|
|
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 |
$5.72 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.71
|
| 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 |
$23.70
|
| Rate for Payer: Blue Shield of California Commercial |
$19.62
|
| Rate for Payer: Blue Shield of California EPN |
$18.55
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.86
|
| Rate for Payer: Dignity Health Senior |
$26.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.56
|
| Rate for Payer: Heritage Provider Network Senior |
$19.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$23.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.64
|
| Rate for Payer: TriValley Medical Group Senior |
$12.64
|
| 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
|
IP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-01
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Adventist Health Commercial |
$5.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.92
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.63
|
| Rate for Payer: Heritage Provider Network Senior |
$19.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.25
|
| Rate for Payer: Multiplan Commercial |
$21.74
|
|
|
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 |
$5.72 |
| Max. Negotiated Rate |
$23.70 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.71
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.39
|
| Rate for Payer: Heritage Provider Network Senior |
$21.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$23.70
|
|
|
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 |
$3.19 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Adventist Health Commercial |
$3.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.10
|
| 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 |
$13.21
|
| Rate for Payer: Blue Shield of California Commercial |
$10.94
|
| Rate for Payer: Blue Shield of California EPN |
$10.34
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.97
|
| Rate for Payer: Dignity Health Senior |
$14.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.90
|
| Rate for Payer: Heritage Provider Network Senior |
$10.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.40
|
| Rate for Payer: Multiplan Commercial |
$13.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.04
|
| Rate for Payer: TriValley Medical Group Senior |
$7.04
|
| 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 66794-237-02
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.69
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.39
|
| Rate for Payer: Heritage Provider Network Senior |
$20.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
|
|
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 |
$5.45 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.69
|
| 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 |
$22.59
|
| Rate for Payer: Blue Shield of California Commercial |
$18.70
|
| Rate for Payer: Blue Shield of California EPN |
$17.68
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.60
|
| Rate for Payer: Dignity Health Senior |
$25.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.64
|
| Rate for Payer: Heritage Provider Network Senior |
$18.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| 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
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-11
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$23.70 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.71
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.39
|
| Rate for Payer: Heritage Provider Network Senior |
$21.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$23.70
|
|
|
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 |
$5.45 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.69
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.39
|
| Rate for Payer: Heritage Provider Network Senior |
$20.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
|
|
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 |
$3.19 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Adventist Health Commercial |
$3.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.10
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.92
|
| Rate for Payer: Heritage Provider Network Senior |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.40
|
| Rate for Payer: Multiplan Commercial |
$13.21
|
|
|
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 |
$5.25 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Adventist Health Commercial |
$5.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.92
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.63
|
| Rate for Payer: Heritage Provider Network Senior |
$19.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.25
|
| Rate for Payer: Multiplan Commercial |
$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 |
$3.19 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Adventist Health Commercial |
$3.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.10
|
| 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 |
$13.21
|
| Rate for Payer: Blue Shield of California Commercial |
$10.94
|
| Rate for Payer: Blue Shield of California EPN |
$10.34
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.97
|
| Rate for Payer: Dignity Health Senior |
$14.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.90
|
| Rate for Payer: Heritage Provider Network Senior |
$10.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.40
|
| Rate for Payer: Multiplan Commercial |
$13.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.04
|
| Rate for Payer: TriValley Medical Group Senior |
$7.04
|
| 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
|
OP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-10
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Adventist Health Commercial |
$5.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.92
|
| 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 |
$21.74
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$17.02
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.64
|
| Rate for Payer: Dignity Health Senior |
$24.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.94
|
| Rate for Payer: Heritage Provider Network Senior |
$17.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.25
|
| Rate for Payer: Multiplan Commercial |
$21.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.60
|
| Rate for Payer: TriValley Medical Group Senior |
$11.60
|
| 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
|
OP
|
$28.99
|
|
|
Service Code
|
NDC 68382-910-01
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Adventist Health Commercial |
$5.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.92
|
| 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 |
$21.74
|
| Rate for Payer: Blue Shield of California Commercial |
$18.00
|
| Rate for Payer: Blue Shield of California EPN |
$17.02
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.64
|
| Rate for Payer: Dignity Health Senior |
$24.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.94
|
| Rate for Payer: Heritage Provider Network Senior |
$17.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.25
|
| Rate for Payer: Multiplan Commercial |
$21.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.60
|
| Rate for Payer: TriValley Medical Group Senior |
$11.60
|
| 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
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 63323-130-11
|
| Hospital Charge Code |
1759448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.71
|
| 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 |
$23.70
|
| Rate for Payer: Blue Shield of California Commercial |
$19.62
|
| Rate for Payer: Blue Shield of California EPN |
$18.55
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.86
|
| Rate for Payer: Dignity Health Senior |
$26.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.56
|
| Rate for Payer: Heritage Provider Network Senior |
$19.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$23.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.64
|
| Rate for Payer: TriValley Medical Group Senior |
$12.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.86
|
| Rate for Payer: Vantage Medical Group Senior |
$26.86
|
|
