|
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 |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
OP
|
$1.79
|
|
|
Service Code
|
NDC 68084-743-32
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.52
|
| Rate for Payer: Dignity Health Senior |
$1.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Vantage Medical Group Senior |
$1.52
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
IP
|
$1.01
|
|
|
Service Code
|
NDC 68382-707-18
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
OP
|
$1.79
|
|
|
Service Code
|
NDC 68084-743-33
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.52
|
| Rate for Payer: Dignity Health Senior |
$1.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Vantage Medical Group Senior |
$1.52
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 68084-743-21
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
IP
|
$1.79
|
|
|
Service Code
|
NDC 68084-743-32
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.23
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 68084-743-21
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 68084-743-11
|
| Hospital Charge Code |
ERX9900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
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 |
$0.18 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.86
|
| Rate for Payer: Dignity Health Senior |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Vantage Medical Group Senior |
$0.86
|
|
|
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 |
$0.18 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.12 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: Dignity Health Senior |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
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 |
$1.18 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.83
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.55
|
| Rate for Payer: Dignity Health Senior |
$5.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Senior |
$4.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$4.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.55
|
| Rate for Payer: Vantage Medical Group Senior |
$5.55
|
|
|
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 |
$1.18 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.49
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$4.90
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
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 |
$0.06 |
| 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
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
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 |
$22.25 |
| Max. Negotiated Rate |
$92.18 |
| Rate for Payer: Adventist Health Commercial |
$24.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$84.44
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$56.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.21
|
| Rate for Payer: Heritage Provider Network Senior |
$83.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.73
|
| Rate for Payer: Multiplan Commercial |
$92.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$44.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.06
|
|
|
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 |
$22.25 |
| Max. Negotiated Rate |
$287.50 |
| Rate for Payer: Adventist Health Commercial |
$24.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$84.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$104.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$67.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$92.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$103.85
|
| Rate for Payer: Blue Shield of California Commercial |
$107.66
|
| Rate for Payer: Blue Shield of California EPN |
$107.66
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cash Price |
$55.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$56.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$104.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$104.47
|
| Rate for Payer: Dignity Health Senior |
$104.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.91
|
| Rate for Payer: Heritage Provider Network Senior |
$56.91
|
| Rate for Payer: IEHP Medi-Cal |
$173.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$59.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.73
|
| Rate for Payer: Multiplan Commercial |
$92.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$44.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$104.47
|
| Rate for Payer: Vantage Medical Group Senior |
$104.47
|
|
|
Drainage of abscess, cyst, hematoma from dentoalveolar structures
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 41800
|
| Min. Negotiated Rate |
$77.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$239.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$175.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$159.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$175.56
|
| Rate for Payer: Dignity Health Senior |
$159.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$159.60
|
| Rate for Payer: Humana Medicare |
$159.60
|
| Rate for Payer: IEHP Medi-Cal |
$77.83
|
| Rate for Payer: IEHP Medicare Advantage |
$159.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$303.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$188.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$201.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$201.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$175.56
|
| Rate for Payer: TriValley Medical Group Senior |
$159.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$239.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$175.56
|
| Rate for Payer: Vantage Medical Group Senior |
$159.60
|
|
|
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 |
$1.12 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.64
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.63
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.25
|
| Rate for Payer: Dignity Health Senior |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.86
|
| Rate for Payer: Heritage Provider Network Senior |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.25
|
| Rate for Payer: Vantage Medical Group Senior |
$5.25
|
|
|
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 |
$1.12 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.25
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.06
|
|
