|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 51672-1275-1
|
| Hospital Charge Code |
1743115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.71
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
IP
|
$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: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$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
|
$0.27
|
|
|
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
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 51672-2002-2
|
| Hospital Charge Code |
1743125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$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
|
$0.18
|
|
|
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 SOLUTION [1768]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 10135-671-81
|
| Hospital Charge Code |
NDG1768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| 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 |
$0.73
|
| 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 Beech St/Commercial/PHCS |
$1.22
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 10135-671-81
|
| Hospital Charge Code |
NDG1768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.22
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
IP
|
$1.63
|
|
|
Service Code
|
NDC 71399-0500-1
|
| Hospital Charge Code |
NDG1768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
NDC 71399-0500-1
|
| Hospital Charge Code |
NDG1768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.98
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 51672-2003-6
|
| Hospital Charge Code |
1749014
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 51672-2003-6
|
| Hospital Charge Code |
1749014
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 24385-110-09
|
| Hospital Charge Code |
1743702
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 24385-110-09
|
| Hospital Charge Code |
1743702
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 51672-2062-0
|
| Hospital Charge Code |
1743702
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
|
|
CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 51672-2062-0
|
| Hospital Charge Code |
1743702
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 51672-4048-1
|
| Hospital Charge Code |
1743470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.01
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 68462-298-17
|
| Hospital Charge Code |
1743470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.61
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 0472-0379-45
|
| Hospital Charge Code |
1743471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 0168-0258-15
|
| Hospital Charge Code |
1743470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.01
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 51672-4048-1
|
| Hospital Charge Code |
1743470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.01
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 0472-0379-45
|
| Hospital Charge Code |
1743471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 0168-0258-15
|
| Hospital Charge Code |
1743470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.01
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 68462-298-17
|
| Hospital Charge Code |
1743470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.61
|
|
|
CLOZAPINE 100 MG TABLET [9647]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 65862-846-01
|
| Hospital Charge Code |
1712218
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.98
|
|
|
CLOZAPINE 100 MG TABLET [9647]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 65862-846-01
|
| Hospital Charge Code |
1712218
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.98
|
|
