|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 68084-536-11
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.23
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0378-3627-93
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.48
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 55111-196-30
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.09
|
| 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 Beech St/Commercial/PHCS |
$0.15
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 68084-536-01
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| 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 |
$0.14
|
| 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 Beech St/Commercial/PHCS |
$0.23
|
|
|
CLOPIDOGREL ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 9994-0802-59
|
| Hospital Charge Code |
1715269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$11.96
|
|
|
CLOPIDOGREL ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 9994-0802-59
|
| Hospital Charge Code |
1715269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$11.96 |
| 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 |
$7.17
|
| 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 Beech St/Commercial/PHCS |
$11.96
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
IP
|
$5.23
|
|
|
Service Code
|
NDC 51672-4044-1
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.92
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 0378-0070-01
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.06 |
| 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 |
$1.24
|
| 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 Beech St/Commercial/PHCS |
$2.06
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 0378-0070-01
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.06
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
OP
|
$5.23
|
|
|
Service Code
|
NDC 51672-4044-1
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.14
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.92
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 9999-4081-86
|
| Hospital Charge Code |
ERX408186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 9999-4081-86
|
| Hospital Charge Code |
ERX408186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.89 |
| 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 |
$0.54
|
| 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 13107-319-01
|
| Hospital Charge Code |
1730086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.89 |
| 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 |
$0.54
|
| 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 13107-319-01
|
| Hospital Charge Code |
1730086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.89
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0054-8146-22
|
| Hospital Charge Code |
1711363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.48
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0054-8146-22
|
| Hospital Charge Code |
1711363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.48 |
| 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 |
$1.49
|
| 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 |
$1.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.48
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 0054-4146-22
|
| Hospital Charge Code |
1711363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.78
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
NDC 0574-0107-70
|
| Hospital Charge Code |
1711363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.16 |
| 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 |
$0.69
|
| 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 Beech St/Commercial/PHCS |
$1.16
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
NDC 0574-0107-70
|
| Hospital Charge Code |
1711363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.16
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 0054-4146-22
|
| Hospital Charge Code |
1711363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.78 |
| 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 |
$1.07
|
| 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 Beech St/Commercial/PHCS |
$1.78
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 45802-434-11
|
| Hospital Charge Code |
1743125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 51672-2002-2
|
| Hospital Charge Code |
1743125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 68001-475-45
|
| Hospital Charge Code |
NDG1767C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0536-1272-22
|
| Hospital Charge Code |
NDG1767A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 51672-1275-1
|
| Hospital Charge Code |
1743115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.71
|
|
