|
CLOMIPRAMINE 25 MG CAPSULE [9635]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 51672-4011-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| 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 |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| 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 Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| 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
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 50268-173-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-861-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$0.63
|
|
|
Service Code
|
NDC 0904-7227-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-861-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-861-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-861-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.63
|
|
|
Service Code
|
NDC 0904-7227-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 50268-173-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 50268-173-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 50268-173-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-872-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 72888-153-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-872-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-872-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 16729-137-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 16729-137-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 72888-153-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.63
|
|
|
Service Code
|
NDC 0904-7728-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.63
|
|
|
Service Code
|
NDC 0904-7728-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.44
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.41
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-872-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
