|
CLONIDINE HCL ER 0.1 MG TABLET,EXTENDED RELEASE,12 HR [107665]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 27241-108-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.27
|
|
|
CLONIDINE HCL ER 0.1 MG TABLET,EXTENDED RELEASE,12 HR [107665]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 27241-108-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.27
|
|
|
CLONIDINE ORAL SUSPENSION COMPOUND 20 MCG/ML [4080258]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0802-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CLONIDINE ORAL SUSPENSION COMPOUND 20 MCG/ML [4080258]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0802-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION [27113]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$16.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.60
|
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$15.75
|
|
|
CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION [27113]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$16.80 |
| Rate for Payer: Cash Price |
$11.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$15.75
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 50268-184-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.62
|
| Rate for Payer: Cash Price |
$5.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$11.52
|
|
|
Service Code
|
NDC 68084-752-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.91
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$11.52
|
|
|
Service Code
|
NDC 68084-752-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 50268-184-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Cash Price |
$5.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 50268-184-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Cash Price |
$5.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 0904-6467-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.56
|
| Rate for Payer: Cash Price |
$8.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Multiplan Commercial |
$11.96
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 50268-184-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.62
|
| Rate for Payer: Cash Price |
$5.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 0904-6467-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Cash Price |
$8.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Multiplan Commercial |
$11.96
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-357-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-357-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-357-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 72205-199-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 55111-196-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 68084-536-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-357-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0378-3627-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 68084-536-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 55111-196-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0378-3627-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
