|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 68382-096-01
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 68084-269-11
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Distinction Transplant |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.64
|
| Rate for Payer: Cigna of CA PPO |
$1.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Media |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$1.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.17
|
| Rate for Payer: United Healthcare All Other HMO |
$1.17
|
| Rate for Payer: United Healthcare HMO Rider |
$1.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 68084-269-11
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.64
|
| Rate for Payer: Cigna of CA PPO |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$1.99
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 69238-1544-1
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Distinction Transplant |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 69238-1544-1
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 68084-269-01
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.64
|
| Rate for Payer: Cigna of CA PPO |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$1.99
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 68382-096-01
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.49
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 68084-269-01
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Distinction Transplant |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.64
|
| Rate for Payer: Cigna of CA PPO |
$1.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Media |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$1.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.17
|
| Rate for Payer: United Healthcare All Other HMO |
$1.17
|
| Rate for Payer: United Healthcare HMO Rider |
$1.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
HYDROXYCHLOROQUINE ORAL SOLUTION COMPOUND 25 MG/ML [4080282]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 9994-0802-82
|
| Hospital Charge Code |
1715011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO |
$3.05
|
| Rate for Payer: Cigna of CA PPO |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.71
|
| Rate for Payer: Global Benefits Group Commercial |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.71
|
|
|
HYDROXYCHLOROQUINE ORAL SOLUTION COMPOUND 25 MG/ML [4080282]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 9994-0802-82
|
| Hospital Charge Code |
1715011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.60
|
| Rate for Payer: Blue Distinction Transplant |
$2.62
|
| Rate for Payer: Blue Shield of California Commercial |
$3.21
|
| Rate for Payer: Blue Shield of California EPN |
$2.55
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO |
$3.05
|
| Rate for Payer: Cigna of CA PPO |
$3.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Media |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.71
|
| Rate for Payer: Global Benefits Group Commercial |
$2.62
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO |
$2.18
|
| Rate for Payer: United Healthcare HMO Rider |
$2.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Vantage Medical Group Senior |
$3.71
|
|
|
HYDROXYPROGESTERONE CAPROATE 250 MG/ML INTRAMUSCULAR OIL [108013]
|
Facility
|
IP
|
$409.09
|
|
|
Service Code
|
CPT J1729
|
| Hospital Charge Code |
ERX108013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.18 |
| Max. Negotiated Rate |
$347.73 |
| Rate for Payer: Blue Shield of California Commercial |
$291.27
|
| Rate for Payer: Blue Shield of California EPN |
$209.45
|
| Rate for Payer: Cash Price |
$184.09
|
| Rate for Payer: Cigna of CA HMO |
$286.36
|
| Rate for Payer: Cigna of CA PPO |
$286.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$163.64
|
| Rate for Payer: Galaxy Health WC |
$347.73
|
| Rate for Payer: Global Benefits Group Commercial |
$245.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$272.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.18
|
| Rate for Payer: Multiplan Commercial |
$327.27
|
| Rate for Payer: Networks By Design Commercial |
$204.54
|
| Rate for Payer: Prime Health Services Commercial |
$347.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$154.47
|
| Rate for Payer: United Healthcare All Other HMO |
$150.87
|
| Rate for Payer: United Healthcare HMO Rider |
$147.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$135.00
|
|
|
HYDROXYPROGESTERONE CAPROATE 250 MG/ML INTRAMUSCULAR OIL [108013]
|
Facility
|
OP
|
$409.09
|
|
|
Service Code
|
CPT J1729
|
| Hospital Charge Code |
ERX108013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.37 |
| Max. Negotiated Rate |
$347.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$84.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.88
|
| Rate for Payer: Blue Distinction Transplant |
$245.45
|
| Rate for Payer: Blue Shield of California Commercial |
$301.50
|
| Rate for Payer: Blue Shield of California EPN |
$16.37
|
| Rate for Payer: Cash Price |
$184.09
|
| Rate for Payer: Cash Price |
$184.09
|
| Rate for Payer: Cigna of CA HMO |
$286.36
|
| Rate for Payer: Cigna of CA PPO |
$286.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.27
|
| Rate for Payer: Dignity Health Media |
$18.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.54
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$18.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.18
|
| Rate for Payer: Galaxy Health WC |
$347.73
|
| Rate for Payer: Global Benefits Group Commercial |
$245.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$306.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.82
|
| Rate for Payer: Heritage Provider Network Transplant |
$29.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$29.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$272.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.36
|
| Rate for Payer: Multiplan Commercial |
$327.27
|
| Rate for Payer: Networks By Design Commercial |
$204.54
|
| Rate for Payer: Prime Health Services Commercial |
$347.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$245.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$245.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$204.54
|
| Rate for Payer: United Healthcare All Other HMO |
$204.54
|
| Rate for Payer: United Healthcare HMO Rider |
$204.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$204.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.00
|
| Rate for Payer: Vantage Medical Group Senior |
$18.18
|
|
|
HYDROXYPROGESTERONE (PF)(PREGNANCY PRESERVING) 250 MG/ML (1 ML) IM OIL [213746]
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
CPT J1726
|
| Hospital Charge Code |
NDG213746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.08 |
| Max. Negotiated Rate |
$290.70 |
| Rate for Payer: Blue Shield of California Commercial |
$243.50
|
| Rate for Payer: Blue Shield of California EPN |
$175.10
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cigna of CA HMO |
$239.40
|
| Rate for Payer: Cigna of CA PPO |
$239.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$136.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$136.80
|
| Rate for Payer: Galaxy Health WC |
$290.70
|
| Rate for Payer: Global Benefits Group Commercial |
$205.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.08
|
| Rate for Payer: Multiplan Commercial |
$273.60
|
| Rate for Payer: Networks By Design Commercial |
$171.00
|
| Rate for Payer: Prime Health Services Commercial |
$290.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$129.14
|
| Rate for Payer: United Healthcare All Other HMO |
$126.13
|
| Rate for Payer: United Healthcare HMO Rider |
$123.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$112.86
|
|
|
HYDROXYPROGESTERONE (PF)(PREGNANCY PRESERVING) 250 MG/ML (1 ML) IM OIL [213746]
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
CPT J1726
|
| Hospital Charge Code |
NDG213746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.08 |
| Max. Negotiated Rate |
$290.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$125.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.21
|
| Rate for Payer: Blue Distinction Transplant |
$205.20
|
| Rate for Payer: Blue Shield of California Commercial |
$252.05
|
| Rate for Payer: Blue Shield of California EPN |
$32.76
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cigna of CA HMO |
$239.40
|
| Rate for Payer: Cigna of CA PPO |
$239.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.13
|
| Rate for Payer: Dignity Health Media |
$12.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.31
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$12.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.08
|
| Rate for Payer: Galaxy Health WC |
$290.70
|
| Rate for Payer: Global Benefits Group Commercial |
$205.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$256.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.82
|
| Rate for Payer: Heritage Provider Network Transplant |
$19.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$19.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.19
|
| Rate for Payer: Multiplan Commercial |
$273.60
|
| Rate for Payer: Networks By Design Commercial |
$171.00
|
| Rate for Payer: Prime Health Services Commercial |
$290.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.00
|
| Rate for Payer: United Healthcare All Other HMO |
$171.00
|
| Rate for Payer: United Healthcare HMO Rider |
$171.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.29
|
| Rate for Payer: Vantage Medical Group Senior |
$12.08
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
CPT S0176
|
| Hospital Charge Code |
1710079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.72
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.94
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
OP
|
$1.10
|
|
|
Service Code
|
CPT S0176
|
| Hospital Charge Code |
1710079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.66
|
| Rate for Payer: Blue Distinction Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Media |
$0.57
|
| Rate for Payer: Dignity Health Media |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.88
|
| Rate for Payer: Networks By Design Commercial |
$0.72
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.55
|
| Rate for Payer: United Healthcare HMO Rider |
$0.55
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
|
HYDROXYUREA ORAL SOLUTION 100 MG/ML [408102360]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
CPT S0176
|
| Hospital Charge Code |
NDC408102360
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
HYDROXYUREA ORAL SOLUTION 100 MG/ML [408102360]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
CPT S0176
|
| Hospital Charge Code |
NDC408102360
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
HYDROXYUREA (SICKLE CELL) 200 MG CAPSULE [23009]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0003-6335-17
|
| Hospital Charge Code |
1710989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
HYDROXYUREA (SICKLE CELL) 200 MG CAPSULE [23009]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 0003-6335-17
|
| Hospital Charge Code |
1710989
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Distinction Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
HYDROXYUREA (SICKLE CELL) 300 MG CAPSULE [23010]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 0003-6336-17
|
| Hospital Charge Code |
1710990
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Distinction Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
HYDROXYUREA (SICKLE CELL) 300 MG CAPSULE [23010]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 0003-6336-17
|
| Hospital Charge Code |
1710990
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 54838-502-80
|
| Hospital Charge Code |
1715474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 54838-502-80
|
| Hospital Charge Code |
1715474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 60432-150-04
|
| Hospital Charge Code |
NDG3771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
