|
HYDROXYZINE HCL 10 MG TABLET [3772]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 23155-500-01
|
| Hospital Charge Code |
1711165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
HYDROXYZINE HCL 10 MG TABLET [3772]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 0093-5060-01
|
| Hospital Charge Code |
1711165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
HYDROXYZINE HCL 10 MG TABLET [3772]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 23155-500-01
|
| Hospital Charge Code |
1711165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
HYDROXYZINE HCL 10 MG TABLET [3772]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 0093-5060-01
|
| Hospital Charge Code |
1711165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
HYDROXYZINE HCL 25 MG TABLET [3774]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 23155-501-01
|
| Hospital Charge Code |
1711178
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
HYDROXYZINE HCL 25 MG TABLET [3774]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 0904-6617-61
|
| Hospital Charge Code |
1711178
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
HYDROXYZINE HCL 25 MG TABLET [3774]
|
Facility
IP
|
$0.31
|
|
|
Service Code
|
NDC 63739-486-10
|
| Hospital Charge Code |
1711178
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
HYDROXYZINE HCL 25 MG TABLET [3774]
|
Facility
OP
|
$0.31
|
|
|
Service Code
|
NDC 63739-486-10
|
| Hospital Charge Code |
1711178
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
HYDROXYZINE HCL 25 MG TABLET [3774]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 23155-501-01
|
| Hospital Charge Code |
1711178
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
HYDROXYZINE HCL 25 MG TABLET [3774]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 0904-6617-61
|
| Hospital Charge Code |
1711178
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]
|
Facility
IP
|
$23.25
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
1720155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$17.44 |
| Rate for Payer: Adventist Health Commercial |
$4.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.97
|
| Rate for Payer: Cash Price |
$10.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.74
|
| Rate for Payer: Heritage Provider Network Senior |
$15.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.81
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.77
|
|
|
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]
|
Facility
OP
|
$23.25
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
1720155
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.21 |
| Max. Negotiated Rate |
$24.35 |
| Rate for Payer: Adventist Health Commercial |
$4.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.58
|
| Rate for Payer: Blue Shield of California Commercial |
$15.55
|
| Rate for Payer: Blue Shield of California EPN |
$15.55
|
| Rate for Payer: Cash Price |
$10.46
|
| Rate for Payer: Cash Price |
$10.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.76
|
| Rate for Payer: Dignity Health Senior |
$19.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.76
|
| Rate for Payer: Heritage Provider Network Senior |
$10.76
|
| Rate for Payer: IEHP Medi-Cal |
$22.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.81
|
| Rate for Payer: Multiplan Commercial |
$17.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.76
|
| Rate for Payer: Vantage Medical Group Senior |
$19.76
|
|
|
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]
|
Facility
OP
|
$33.19
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
NDG3770
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$28.21 |
| Rate for Payer: Adventist Health Commercial |
$6.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.58
|
| Rate for Payer: Blue Shield of California Commercial |
$15.55
|
| Rate for Payer: Blue Shield of California EPN |
$15.55
|
| Rate for Payer: Cash Price |
$14.94
|
| Rate for Payer: Cash Price |
$14.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.21
|
| Rate for Payer: Dignity Health Senior |
$28.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.37
|
| Rate for Payer: Heritage Provider Network Senior |
$15.37
|
| Rate for Payer: IEHP Medi-Cal |
$22.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.30
|
| Rate for Payer: Multiplan Commercial |
$24.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.21
|
| Rate for Payer: Vantage Medical Group Senior |
$28.21
|
|
|
HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]
|
Facility
IP
|
$33.19
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
NDG3770
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$24.89 |
| Rate for Payer: Adventist Health Commercial |
$6.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.80
|
| Rate for Payer: Cash Price |
$14.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.47
|
| Rate for Payer: Heritage Provider Network Senior |
$22.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.30
|
| Rate for Payer: Multiplan Commercial |
$24.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.09
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 23155-502-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| 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 |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 10702-012-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 68084-255-11
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 23155-502-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| 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 |
$0.08
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 9992-0012-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 10702-012-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
IP
|
$0.46
|
|
|
Service Code
|
NDC 68084-255-11
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 68084-255-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 9992-0012-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
IP
|
$0.46
|
|
|
Service Code
|
NDC 68084-255-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 0093-5062-01
|
| Hospital Charge Code |
1711188
|
|
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
|
|
