|
DOXYCYCLINE 10 MG/ML TOPICAL [4081094]
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
NDC 99994-0810-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.42
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.46
|
| Rate for Payer: Dignity Health Senior |
$2.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Senior |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.03
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Senior |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.46
|
| Rate for Payer: Vantage Medical Group Senior |
$2.46
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-65
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$1.11
|
| 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
|
$1.61
|
|
|
Service Code
|
NDC 50268-278-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-65
|
| Hospital Charge Code |
901700029
|
|
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 |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.11
|
| 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 |
$0.96
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| 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: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| 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
|
$1.44
|
|
|
Service Code
|
NDC 0143-3142-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-11
|
| Hospital Charge Code |
901700029
|
|
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 |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.11
|
| 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 |
$0.96
|
| 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: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| 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: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.71
|
| 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
|
$0.34
|
|
|
Service Code
|
NDC 69238-1100-2
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.18
|
| 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
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 69238-1100-2
|
| Hospital Charge Code |
901700029
|
|
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: 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 |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 50268-278-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0143-9803-50
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.18
|
| 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
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0143-9803-50
|
| Hospital Charge Code |
901700029
|
|
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: 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 |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 0904-0428-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Senior |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 50268-278-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Senior |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
NDC 0904-0428-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.08
|
| Rate for Payer: Dignity Health Senior |
$2.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Vantage Medical Group Senior |
$2.08
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
NDC 0143-3142-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 50268-278-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Senior |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687-513-11
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$1.11
|
| 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 INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$23.70 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Adventist Health Commercial |
$3.52
|
| Rate for Payer: Adventist Health Commercial |
$5.80
|
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cash Price |
$16.57
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.15
|
| Rate for Payer: Heritage Provider Network Senior |
$13.42
|
| Rate for Payer: Heritage Provider Network Senior |
$8.15
|
| Rate for Payer: Heritage Provider Network Senior |
$9.26
|
| Rate for Payer: Heritage Provider Network Senior |
$13.95
|
| Rate for Payer: Heritage Provider Network Senior |
$14.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$15.01
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
| Rate for Payer: Multiplan Commercial |
$13.21
|
| Rate for Payer: Multiplan Commercial |
$23.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.46
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Adventist Health Commercial |
$3.52
|
| Rate for Payer: Adventist Health Commercial |
$5.80
|
| Rate for Payer: Adventist Health Commercial |
$6.02
|
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$17.68
|
| Rate for Payer: Blue Shield of California Commercial |
$10.74
|
| Rate for Payer: Blue Shield of California Commercial |
$12.21
|
| Rate for Payer: Blue Shield of California Commercial |
$18.37
|
| Rate for Payer: Blue Shield of California Commercial |
$19.28
|
| Rate for Payer: Blue Shield of California EPN |
$9.76
|
| Rate for Payer: Blue Shield of California EPN |
$8.59
|
| Rate for Payer: Blue Shield of California EPN |
$15.42
|
| Rate for Payer: Blue Shield of California EPN |
$14.70
|
| Rate for Payer: Blue Shield of California EPN |
$14.15
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cash Price |
$16.57
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Cash Price |
$15.95
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cash Price |
$16.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.01
|
| Rate for Payer: Dignity Health Senior |
$24.64
|
| Rate for Payer: Dignity Health Senior |
$14.97
|
| Rate for Payer: Dignity Health Senior |
$17.01
|
| Rate for Payer: Dignity Health Senior |
$26.86
|
| Rate for Payer: Dignity Health Senior |
$25.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.15
|
| Rate for Payer: Heritage Provider Network Senior |
$13.42
|
| Rate for Payer: Heritage Provider Network Senior |
$13.95
|
| Rate for Payer: Heritage Provider Network Senior |
$14.63
|
| Rate for Payer: Heritage Provider Network Senior |
$8.15
|
| Rate for Payer: Heritage Provider Network Senior |
$9.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.01
|
| Rate for Payer: Multiplan Commercial |
$22.59
|
| Rate for Payer: Multiplan Commercial |
$21.74
|
| Rate for Payer: Multiplan Commercial |
$13.21
|
| Rate for Payer: Multiplan Commercial |
$15.01
|
| Rate for Payer: Multiplan Commercial |
$23.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.64
|
| Rate for Payer: TriValley Medical Group Senior |
$7.04
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$11.60
|
| Rate for Payer: TriValley Medical Group Senior |
$8.00
|
| Rate for Payer: TriValley Medical Group Senior |
$12.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.60
|
| Rate for Payer: Vantage Medical Group Senior |
$25.60
|
| Rate for Payer: Vantage Medical Group Senior |
$14.97
|
| Rate for Payer: Vantage Medical Group Senior |
$17.01
|
| Rate for Payer: Vantage Medical Group Senior |
$26.86
|
| Rate for Payer: Vantage Medical Group Senior |
$24.64
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
901700004
|
|
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: Cash Price |
$17.38
|
| 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 FOR SCLEROSIS [4082622]
|
Facility
|
OP
|
$20.80
|
|
|
Service Code
|
NDC 63323-130-17
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$17.68 |
| Rate for Payer: Adventist Health Commercial |
$4.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.60
|
| Rate for Payer: Blue Shield of California Commercial |
$12.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.15
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.68
|
| Rate for Payer: Dignity Health Senior |
$17.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.88
|
| Rate for Payer: Heritage Provider Network Senior |
$12.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.56
|
| Rate for Payer: Multiplan Commercial |
$15.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.32
|
| Rate for Payer: TriValley Medical Group Senior |
$8.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.68
|
| Rate for Payer: Vantage Medical Group Senior |
$17.68
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$19.28
|
| Rate for Payer: Blue Shield of California EPN |
$15.42
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cash Price |
$17.38
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| 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: Molina Healthcare of CA Medi-Cal |
$22.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.12
|
| 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: United Healthcare All Other HMO/non HMO |
$15.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$20.80
|
|
|
Service Code
|
NDC 63323-130-17
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Adventist Health Commercial |
$4.16
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.08
|
| Rate for Payer: Heritage Provider Network Senior |
$14.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.20
|
| Rate for Payer: Multiplan Commercial |
$15.60
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET [2625]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 42806-312-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET [2625]
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 0904-0430-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
|
