|
HYDROXYZINE HCL 50 MG TABLET [3775]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
NDC 0093-5062-01
|
| Hospital Charge Code |
1711188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| 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: 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: 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
|
|
|
HYDROXYZINE ORAL SOLUTION (IV FORM) 50 MG/ML [4080433]
|
Facility
OP
|
$2.40
|
|
|
Service Code
|
NDC 9994-0804-33
|
| Hospital Charge Code |
1715147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.41
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Senior |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
HYDROXYZINE ORAL SOLUTION (IV FORM) 50 MG/ML [4080433]
|
Facility
IP
|
$2.40
|
|
|
Service Code
|
NDC 9994-0804-33
|
| Hospital Charge Code |
1715147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 0555-0323-02
|
| Hospital Charge Code |
1711071
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 0555-0323-02
|
| Hospital Charge Code |
1711071
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]
|
Facility
OP
|
$273.92
|
|
|
Service Code
|
CPT J7325
|
| Hospital Charge Code |
1721174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$205.44 |
| Rate for Payer: Adventist Health Commercial |
$54.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$31.30
|
| Rate for Payer: Blue Shield of California Commercial |
$29.10
|
| Rate for Payer: Blue Shield of California EPN |
$29.10
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.03
|
| Rate for Payer: Dignity Health Senior |
$10.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.82
|
| Rate for Payer: Heritage Provider Network Senior |
$126.82
|
| Rate for Payer: Humana Medicare |
$9.12
|
| Rate for Payer: IEHP Medi-Cal |
$21.18
|
| Rate for Payer: IEHP Medicare Advantage |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.49
|
| Rate for Payer: Multiplan Commercial |
$205.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.03
|
| Rate for Payer: TriValley Medical Group Senior |
$9.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$91.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.03
|
| Rate for Payer: Vantage Medical Group Senior |
$9.12
|
|
|
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]
|
Facility
IP
|
$273.92
|
|
|
Service Code
|
CPT J7325
|
| Hospital Charge Code |
1721174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.58 |
| Max. Negotiated Rate |
$205.44 |
| Rate for Payer: Adventist Health Commercial |
$54.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.18
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$147.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$185.44
|
| Rate for Payer: Heritage Provider Network Senior |
$185.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.48
|
| Rate for Payer: Multiplan Commercial |
$205.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$91.52
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 39328-048-16
|
| Hospital Charge Code |
NDG3781
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 39328-048-16
|
| Hospital Charge Code |
NDG3781
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 54838-511-80
|
| Hospital Charge Code |
NDG3781
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| 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 |
$0.06
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 54838-511-80
|
| Hospital Charge Code |
NDG3781
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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 |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| 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 Commercial |
$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 |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS [3782]
|
Facility
OP
|
$2.65
|
|
|
Service Code
|
NDC 39328-047-15
|
| Hospital Charge Code |
1719158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.25
|
| Rate for Payer: Dignity Health Senior |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Senior |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.25
|
| Rate for Payer: Vantage Medical Group Senior |
$2.25
|
|
|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS [3782]
|
Facility
IP
|
$2.65
|
|
|
Service Code
|
NDC 39328-047-15
|
| Hospital Charge Code |
1719158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.82
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.79
|
| Rate for Payer: Heritage Provider Network Senior |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$1.99
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
OP
|
$0.82
|
|
|
Service Code
|
NDC 43199-011-01
|
| Hospital Charge Code |
1711556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
IP
|
$0.54
|
|
|
Service Code
|
NDC 42192-339-01
|
| Hospital Charge Code |
1711556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
OP
|
$0.54
|
|
|
Service Code
|
NDC 42192-339-01
|
| Hospital Charge Code |
1711556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Senior |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
IP
|
$0.82
|
|
|
Service Code
|
NDC 43199-011-01
|
| Hospital Charge Code |
1711556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| 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
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
IP
|
$80.30
|
|
|
Service Code
|
CPT J1980
|
| Hospital Charge Code |
1720837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$60.22 |
| Rate for Payer: Adventist Health Commercial |
$16.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.17
|
| Rate for Payer: Cash Price |
$36.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.36
|
| Rate for Payer: Heritage Provider Network Senior |
$54.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.08
|
| Rate for Payer: Multiplan Commercial |
$60.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.83
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
OP
|
$80.30
|
|
|
Service Code
|
CPT J1980
|
| Hospital Charge Code |
1720837
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$87.12 |
| Rate for Payer: Adventist Health Commercial |
$16.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$87.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$60.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.51
|
| Rate for Payer: Blue Shield of California Commercial |
$30.26
|
| Rate for Payer: Blue Shield of California EPN |
$30.26
|
| Rate for Payer: Cash Price |
$36.14
|
| Rate for Payer: Cash Price |
$36.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.26
|
| Rate for Payer: Dignity Health Senior |
$68.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.18
|
| Rate for Payer: Heritage Provider Network Senior |
$37.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.08
|
| Rate for Payer: Multiplan Commercial |
$60.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.26
|
| Rate for Payer: Vantage Medical Group Senior |
$68.26
|
|
|
HYPERTENSION
|
Facility
IP
|
$4,442.21
|
|
|
Service Code
|
APR-DRG 1991
|
| Min. Negotiated Rate |
$4,442.21 |
| Max. Negotiated Rate |
$4,442.21 |
| Rate for Payer: IEHP Medi-Cal |
$4,442.21
|
|
|
HYPERTENSION
|
Facility
IP
|
$7,476.65
|
|
|
Service Code
|
APR-DRG 1993
|
| Min. Negotiated Rate |
$7,476.65 |
| Max. Negotiated Rate |
$7,476.65 |
| Rate for Payer: IEHP Medi-Cal |
$7,476.65
|
|
|
HYPERTENSION
|
Facility
IP
|
$10,917.99
|
|
|
Service Code
|
APR-DRG 1994
|
| Min. Negotiated Rate |
$10,917.99 |
| Max. Negotiated Rate |
$10,917.99 |
| Rate for Payer: IEHP Medi-Cal |
$10,917.99
|
|
|
HYPERTENSION
|
Facility
IP
|
$5,428.16
|
|
|
Service Code
|
APR-DRG 1992
|
| Min. Negotiated Rate |
$5,428.16 |
| Max. Negotiated Rate |
$5,428.16 |
| Rate for Payer: IEHP Medi-Cal |
$5,428.16
|
|
|
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS
|
Facility
IP
|
$2,971.75
|
|
|
Service Code
|
APR-DRG 4221
|
| Min. Negotiated Rate |
$2,971.75 |
| Max. Negotiated Rate |
$2,971.75 |
| Rate for Payer: IEHP Medi-Cal |
$2,971.75
|
|
|
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS
|
Facility
IP
|
$4,424.31
|
|
|
Service Code
|
APR-DRG 4222
|
| Min. Negotiated Rate |
$4,424.31 |
| Max. Negotiated Rate |
$4,424.31 |
| Rate for Payer: IEHP Medi-Cal |
$4,424.31
|
|
