|
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
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 9994-0802-59
|
| 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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 9994-0802-59
|
| 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
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 51672-4044-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 51672-4044-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.65
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 9999-4081-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 9999-4081-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 51672-4042-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 13107-319-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
NDC 60505-4754-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.89
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 13107-319-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
NDC 60505-4754-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 51672-4042-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
NDC 0574-0107-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.92
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 0054-4146-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
NDC 0574-0107-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0054-8146-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.98
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0054-8146-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 0054-4146-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.43
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 45802-434-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 45802-434-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 10135-671-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 10135-671-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
|
