|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$11.52
|
|
|
Service Code
|
NDC 6808475219
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$5.84
|
| Rate for Payer: Blue Shield of California Commercial |
$8.86
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO |
$8.06
|
| Rate for Payer: Cigna of CA PPO |
$8.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: EPIC Health Plan Senior |
$4.61
|
| Rate for Payer: Galaxy Health WC |
$9.79
|
| Rate for Payer: Global Benefits Group Commercial |
$6.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
| Rate for Payer: Networks By Design Commercial |
$7.49
|
| Rate for Payer: Prime Health Services Commercial |
$9.79
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 5026818412
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California Commercial |
$4.75
|
| Rate for Payer: Blue Shield of California Commercial |
$7.21
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO |
$6.56
|
| Rate for Payer: Cigna of CA PPO |
$6.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.75
|
| Rate for Payer: EPIC Health Plan Senior |
$3.75
|
| Rate for Payer: Galaxy Health WC |
$7.96
|
| Rate for Payer: Global Benefits Group Commercial |
$5.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$7.50
|
| Rate for Payer: Networks By Design Commercial |
$6.09
|
| Rate for Payer: Prime Health Services Commercial |
$7.96
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 5026818411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California Commercial |
$4.75
|
| Rate for Payer: Blue Shield of California Commercial |
$7.21
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO |
$6.56
|
| Rate for Payer: Cigna of CA PPO |
$6.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.75
|
| Rate for Payer: EPIC Health Plan Senior |
$3.75
|
| Rate for Payer: Galaxy Health WC |
$7.96
|
| Rate for Payer: Global Benefits Group Commercial |
$5.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$7.50
|
| Rate for Payer: Networks By Design Commercial |
$6.09
|
| Rate for Payer: Prime Health Services Commercial |
$7.96
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$11.52
|
|
|
Service Code
|
NDC 6808475219
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.39
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO |
$8.06
|
| Rate for Payer: Cigna of CA PPO |
$8.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: EPIC Health Plan Senior |
$4.61
|
| Rate for Payer: Galaxy Health WC |
$9.79
|
| Rate for Payer: Global Benefits Group Commercial |
$6.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
| Rate for Payer: Networks By Design Commercial |
$7.49
|
| Rate for Payer: Prime Health Services Commercial |
$9.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.76
|
| Rate for Payer: United Healthcare All Other HMO |
$5.76
|
| Rate for Payer: United Healthcare HMO Rider |
$5.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Vantage Medical Group Senior |
$9.79
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 5026818412
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.01
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO |
$6.56
|
| Rate for Payer: Cigna of CA PPO |
$6.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.75
|
| Rate for Payer: EPIC Health Plan Senior |
$3.75
|
| Rate for Payer: Galaxy Health WC |
$7.96
|
| Rate for Payer: Global Benefits Group Commercial |
$5.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$7.50
|
| Rate for Payer: Networks By Design Commercial |
$6.09
|
| Rate for Payer: Prime Health Services Commercial |
$7.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Other HMO |
$4.68
|
| Rate for Payer: United Healthcare HMO Rider |
$4.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.96
|
| Rate for Payer: Vantage Medical Group Senior |
$7.96
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 5026818411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.01
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO |
$6.56
|
| Rate for Payer: Cigna of CA PPO |
$6.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.75
|
| Rate for Payer: EPIC Health Plan Senior |
$3.75
|
| Rate for Payer: Galaxy Health WC |
$7.96
|
| Rate for Payer: Global Benefits Group Commercial |
$5.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$7.50
|
| Rate for Payer: Networks By Design Commercial |
$6.09
|
| Rate for Payer: Prime Health Services Commercial |
$7.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Other HMO |
$4.68
|
| Rate for Payer: United Healthcare HMO Rider |
$4.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.96
|
| Rate for Payer: Vantage Medical Group Senior |
$7.96
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 0904646707
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$8.08
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO |
$11.16
|
| Rate for Payer: Cigna of CA PPO |
$11.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.38
|
| Rate for Payer: EPIC Health Plan Senior |
$6.38
|
| Rate for Payer: Galaxy Health WC |
$13.55
|
| Rate for Payer: Global Benefits Group Commercial |
$9.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$13.55
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 6808453611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6586235730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 7220519990
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6586235790
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0378362793
|
| 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 |
$0.42
|
| 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 |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| 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
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6586235730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 7220519990
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0378362793
|
| 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 |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6586235790
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 6808453601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 5511119630
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 6808453601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 5511119630
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 6808453611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
CLOPIDOGREL ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 9994080259
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.23
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO |
$11.16
|
| Rate for Payer: Cigna of CA PPO |
$11.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.38
|
| Rate for Payer: EPIC Health Plan Senior |
$6.38
|
| Rate for Payer: Galaxy Health WC |
$13.55
|
| Rate for Payer: Global Benefits Group Commercial |
$9.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.16
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$13.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.97
|
| Rate for Payer: United Healthcare All Other HMO |
$7.97
|
| Rate for Payer: United Healthcare HMO Rider |
$7.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.55
|
| Rate for Payer: Vantage Medical Group Senior |
$13.55
|
|
|
CLOPIDOGREL ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 9994080259
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$8.08
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO |
$11.16
|
| Rate for Payer: Cigna of CA PPO |
$11.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.38
|
| Rate for Payer: EPIC Health Plan Senior |
$6.38
|
| Rate for Payer: Galaxy Health WC |
$13.55
|
| Rate for Payer: Global Benefits Group Commercial |
$9.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$12.75
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$13.55
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 5167240441
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| 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 |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Senior |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.65
|
| 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 |
$2.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 5167240441
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Senior |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.34
|
|
