|
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 |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
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 |
$0.42 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Senior |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| 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 |
$0.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
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 |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| 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
OP
|
$2.34
|
|
|
Service Code
|
NDC 68084-269-11
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Senior |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| 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 68084-269-01
|
| Hospital Charge Code |
1710362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
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 |
$0.79 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Blue Shield of California Commercial |
$2.71
|
| Rate for Payer: Blue Shield of California EPN |
$2.56
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.71
|
| Rate for Payer: Dignity Health Senior |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Senior |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.10
|
| 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 |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Vantage Medical Group Senior |
$3.71
|
|
|
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 |
$0.79 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.00
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| 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 |
$3.27
|
|
|
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 |
$13.91 |
| Max. Negotiated Rate |
$306.82 |
| Rate for Payer: Adventist Health Commercial |
$81.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$281.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.97
|
| Rate for Payer: Blue Shield of California Commercial |
$13.91
|
| Rate for Payer: Blue Shield of California EPN |
$13.91
|
| Rate for Payer: Cash Price |
$184.09
|
| Rate for Payer: Cash Price |
$184.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$188.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.00
|
| Rate for Payer: Dignity Health Senior |
$20.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$261.82
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$189.41
|
| Rate for Payer: Heritage Provider Network Senior |
$189.41
|
| Rate for Payer: Humana Medicare |
$18.18
|
| Rate for Payer: IEHP Medi-Cal |
$28.24
|
| Rate for Payer: IEHP Medicare Advantage |
$18.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$102.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.91
|
| Rate for Payer: Multiplan Commercial |
$306.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.00
|
| Rate for Payer: TriValley Medical Group Senior |
$18.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$149.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$136.68
|
| 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 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 |
$74.05 |
| Max. Negotiated Rate |
$306.82 |
| Rate for Payer: Adventist Health Commercial |
$81.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$281.04
|
| Rate for Payer: Cash Price |
$184.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$188.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$220.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.95
|
| Rate for Payer: Heritage Provider Network Senior |
$276.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$74.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$102.27
|
| Rate for Payer: Multiplan Commercial |
$306.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$149.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$136.68
|
|
|
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 |
$61.90 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Adventist Health Commercial |
$68.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.95
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$157.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$184.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$231.53
|
| Rate for Payer: Heritage Provider Network Senior |
$231.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$256.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$124.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$114.26
|
|
|
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 |
$256.50 |
| Rate for Payer: Adventist Health Commercial |
$68.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$234.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.38
|
| Rate for Payer: Blue Shield of California Commercial |
$20.57
|
| Rate for Payer: Blue Shield of California EPN |
$20.57
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$157.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.29
|
| Rate for Payer: Dignity Health Senior |
$13.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$218.88
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$158.35
|
| Rate for Payer: Heritage Provider Network Senior |
$158.35
|
| Rate for Payer: Humana Medicare |
$12.08
|
| Rate for Payer: IEHP Medicare Advantage |
$12.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.23
|
| Rate for Payer: Multiplan Commercial |
$256.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.29
|
| Rate for Payer: TriValley Medical Group Senior |
$12.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$124.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$114.26
|
| 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
|
$1.10
|
|
|
Service Code
|
CPT S0176
|
| Hospital Charge Code |
1710079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
OP
|
$1.10
|
|
|
Service Code
|
CPT S0176
|
| Hospital Charge Code |
1710079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Senior |
$0.94
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| 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 |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| 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/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| 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 |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
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 |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
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 |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
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 |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| 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 |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 60432-150-04
|
| Hospital Charge Code |
NDG3771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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 |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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 60432-150-04
|
| Hospital Charge Code |
NDG3771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
