|
HYDRALAZINE 10 MG TABLET [3698]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 51079-074-01
|
| Hospital Charge Code |
1711080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]
|
Facility
|
OP
|
$50.95
|
|
|
Service Code
|
CPT J0360
|
| Hospital Charge Code |
1720072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.02 |
| Max. Negotiated Rate |
$38.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$30.57
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.64
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$30.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Cash Price |
$22.93
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cash Price |
$7.73
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$30.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$38.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.80
|
|
|
HYDRALAZINE 20 MG/ML INJECTION SOLUTION [3697]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
CPT J0360
|
| Hospital Charge Code |
1720072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$22.93
|
| Rate for Payer: Cash Price |
$7.73
|
| Rate for Payer: Cash Price |
$6.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$38.21
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 64380-734-06
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 62584-733-11
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 64380-734-06
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 62584-733-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 62584-733-11
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 62584-733-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 51079-075-20
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 51079-075-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 23155-002-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 31722-520-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 51079-075-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 31722-520-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 23155-002-01
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
HYDRALAZINE 25 MG TABLET [3700]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 51079-075-20
|
| Hospital Charge Code |
1710572
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 64380-735-06
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0904-6442-61
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 23155-003-01
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 62584-734-11
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.28
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 23155-003-01
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0904-6442-61
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 31722-521-01
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
HYDRALAZINE 50 MG TABLET [3701]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 62584-734-11
|
| Hospital Charge Code |
1710584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.28
|
|
