|
CLOBAZAM 10 MG/4 ML ORAL SUSPENSION [201477]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 69238-1535-2
|
| Hospital Charge Code |
NDG201477
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 42571-315-01
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$1.22
|
| Rate for Payer: Cigna of CA PPO |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.48
|
| Rate for Payer: Global Benefits Group Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: Networks By Design Commercial |
$1.13
|
| Rate for Payer: Prime Health Services Commercial |
$1.48
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 60687-423-21
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.86
|
| Rate for Payer: Blue Distinction Transplant |
$1.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.18
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.65
|
| Rate for Payer: Dignity Health Media |
$2.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.25
|
| Rate for Payer: Galaxy Health WC |
$2.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Networks By Design Commercial |
$2.03
|
| Rate for Payer: Prime Health Services Commercial |
$2.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2.65
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 60687-423-21
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.18
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Galaxy Health WC |
$2.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Networks By Design Commercial |
$2.03
|
| Rate for Payer: Prime Health Services Commercial |
$2.65
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 42571-315-01
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.04
|
| Rate for Payer: Blue Distinction Transplant |
$1.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$1.22
|
| Rate for Payer: Cigna of CA PPO |
$1.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.48
|
| Rate for Payer: Dignity Health Media |
$1.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.48
|
| Rate for Payer: Global Benefits Group Commercial |
$1.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: Networks By Design Commercial |
$1.13
|
| Rate for Payer: Prime Health Services Commercial |
$1.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO |
$0.87
|
| Rate for Payer: United Healthcare HMO Rider |
$0.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.48
|
| Rate for Payer: Vantage Medical Group Senior |
$1.48
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 69238-1305-1
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 60687-423-11
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.18
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Galaxy Health WC |
$2.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Networks By Design Commercial |
$2.03
|
| Rate for Payer: Prime Health Services Commercial |
$2.65
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 60687-423-11
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.86
|
| Rate for Payer: Blue Distinction Transplant |
$1.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.18
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.65
|
| Rate for Payer: Dignity Health Media |
$2.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.25
|
| Rate for Payer: Galaxy Health WC |
$2.65
|
| Rate for Payer: Global Benefits Group Commercial |
$1.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Networks By Design Commercial |
$2.03
|
| Rate for Payer: Prime Health Services Commercial |
$2.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2.65
|
|
|
CLOBAZAM 10 MG TABLET [153175]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 69238-1305-1
|
| Hospital Charge Code |
1730194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
CLOBAZAM 20 MG TABLET [153176]
|
Facility
|
IP
|
$65.95
|
|
|
Service Code
|
NDC 67386-315-01
|
| Hospital Charge Code |
ERX153176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$56.06 |
| Rate for Payer: Blue Shield of California Commercial |
$46.96
|
| Rate for Payer: Blue Shield of California EPN |
$33.77
|
| Rate for Payer: Cash Price |
$29.68
|
| Rate for Payer: Cigna of CA HMO |
$46.16
|
| Rate for Payer: Cigna of CA PPO |
$46.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.38
|
| Rate for Payer: Galaxy Health WC |
$56.06
|
| Rate for Payer: Global Benefits Group Commercial |
$39.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$43.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.83
|
| Rate for Payer: Multiplan Commercial |
$52.76
|
| Rate for Payer: Networks By Design Commercial |
$42.87
|
| Rate for Payer: Prime Health Services Commercial |
$56.06
|
|
|
CLOBAZAM 20 MG TABLET [153176]
|
Facility
|
OP
|
$65.95
|
|
|
Service Code
|
NDC 67386-315-01
|
| Hospital Charge Code |
ERX153176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$56.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$43.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.29
|
| Rate for Payer: Blue Distinction Transplant |
$39.57
|
| Rate for Payer: Blue Shield of California Commercial |
$48.61
|
| Rate for Payer: Blue Shield of California EPN |
$38.51
|
| Rate for Payer: Cash Price |
$29.68
|
| Rate for Payer: Cigna of CA HMO |
$46.16
|
| Rate for Payer: Cigna of CA PPO |
$46.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.06
|
| Rate for Payer: Dignity Health Media |
$56.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.38
|
| Rate for Payer: Galaxy Health WC |
$56.06
|
| Rate for Payer: Global Benefits Group Commercial |
$39.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$49.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$43.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.83
|
| Rate for Payer: Multiplan Commercial |
$52.76
|
| Rate for Payer: Networks By Design Commercial |
$42.87
|
| Rate for Payer: Prime Health Services Commercial |
$56.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$39.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$39.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.98
|
| Rate for Payer: United Healthcare All Other HMO |
$32.98
|
| Rate for Payer: United Healthcare HMO Rider |
$32.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$32.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.06
|
| Rate for Payer: Vantage Medical Group Senior |
$56.06
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM [9630]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 51672-1258-1
|
| Hospital Charge Code |
NDG9630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM [9630]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 42291-076-15
|
| Hospital Charge Code |
NDG9630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM [9630]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 51672-1258-2
|
| Hospital Charge Code |
1743720
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM [9630]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 42291-076-15
|
| Hospital Charge Code |
NDG9630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM [9630]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 51672-1258-1
|
| Hospital Charge Code |
NDG9630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM [9630]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 51672-1258-2
|
| Hospital Charge Code |
1743720
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
CLOBETASOL 0.05 % TOPICAL GEL [13203]
|
Facility
|
OP
|
$2.76
|
|
|
Service Code
|
NDC 45802-925-94
|
| Hospital Charge Code |
NDG2152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.64
|
| Rate for Payer: Blue Distinction Transplant |
$1.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.93
|
| Rate for Payer: Cigna of CA PPO |
$1.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: Dignity Health Media |
$2.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
CLOBETASOL 0.05 % TOPICAL GEL [13203]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 51672-1294-2
|
| Hospital Charge Code |
NDG2152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
|
|
CLOBETASOL 0.05 % TOPICAL GEL [13203]
|
Facility
|
IP
|
$2.76
|
|
|
Service Code
|
NDC 45802-925-94
|
| Hospital Charge Code |
NDG2152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Blue Shield of California Commercial |
$1.97
|
| Rate for Payer: Blue Shield of California EPN |
$1.41
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.93
|
| Rate for Payer: Cigna of CA PPO |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.21
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.35
|
|
|
CLOBETASOL 0.05 % TOPICAL GEL [13203]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 51672-1294-2
|
| Hospital Charge Code |
NDG2152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.55
|
| Rate for Payer: Blue Distinction Transplant |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Media |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
CLOMIPRAMINE 25 MG CAPSULE [9635]
|
Facility
|
IP
|
$5.83
|
|
|
Service Code
|
NDC 59746-710-30
|
| Hospital Charge Code |
1711836
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Blue Shield of California Commercial |
$4.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.98
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cigna of CA HMO |
$4.08
|
| Rate for Payer: Cigna of CA PPO |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Galaxy Health WC |
$4.96
|
| Rate for Payer: Global Benefits Group Commercial |
$3.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.66
|
| Rate for Payer: Networks By Design Commercial |
$3.79
|
| Rate for Payer: Prime Health Services Commercial |
$4.96
|
|
|
CLOMIPRAMINE 25 MG CAPSULE [9635]
|
Facility
|
OP
|
$5.83
|
|
|
Service Code
|
NDC 59746-710-30
|
| Hospital Charge Code |
1711836
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.47
|
| Rate for Payer: Blue Distinction Transplant |
$3.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4.30
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cigna of CA HMO |
$4.08
|
| Rate for Payer: Cigna of CA PPO |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.96
|
| Rate for Payer: Dignity Health Media |
$4.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.33
|
| Rate for Payer: Galaxy Health WC |
$4.96
|
| Rate for Payer: Global Benefits Group Commercial |
$3.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.66
|
| Rate for Payer: Networks By Design Commercial |
$3.79
|
| Rate for Payer: Prime Health Services Commercial |
$4.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.92
|
| Rate for Payer: United Healthcare All Other HMO |
$2.92
|
| Rate for Payer: United Healthcare HMO Rider |
$2.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4.96
|
|
|
CLOMIPRAMINE 25 MG CAPSULE [9635]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 27241-210-30
|
| Hospital Charge Code |
1711836
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Distinction Transplant |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Media |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CLOMIPRAMINE 25 MG CAPSULE [9635]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 51672-4011-6
|
| Hospital Charge Code |
1711836
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Blue Shield of California Commercial |
$5.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
