|
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 |
$1.06 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Adventist Health Commercial |
$1.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.01
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.95
|
| Rate for Payer: Heritage Provider Network Senior |
$3.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.37
|
|
|
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 |
$1.06 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Adventist Health Commercial |
$1.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.01
|
| 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 |
$4.37
|
| Rate for Payer: Blue Shield of California Commercial |
$3.62
|
| Rate for Payer: Blue Shield of California EPN |
$3.42
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.96
|
| Rate for Payer: Dignity Health Senior |
$4.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.33
|
| Rate for Payer: TriValley Medical Group Senior |
$2.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4.96
|
|
|
CLOMIPRAMINE 50 MG CAPSULE [1754]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 27241-211-30
|
| Hospital Charge Code |
1711837
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
CLOMIPRAMINE 50 MG CAPSULE [1754]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 27241-211-30
|
| Hospital Charge Code |
1711837
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| 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: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| 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
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-544-01
|
| Hospital Charge Code |
1730122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| 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: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| 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
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 16729-136-00
|
| Hospital Charge Code |
1730122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-544-11
|
| Hospital Charge Code |
1730122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-544-01
|
| Hospital Charge Code |
1730122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
CLONAZEPAM 0.5 MG TABLET [9637]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-544-11
|
| Hospital Charge Code |
1730122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| 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: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| 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
|
$0.05
|
|
|
Service Code
|
NDC 16729-136-00
|
| Hospital Charge Code |
1730122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-01
|
| Hospital Charge Code |
1730123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-11
|
| Hospital Charge Code |
1730123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-01
|
| Hospital Charge Code |
1730123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| 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: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| 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
|
$0.05
|
|
|
Service Code
|
NDC 16729-137-00
|
| Hospital Charge Code |
1730123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 16729-137-00
|
| Hospital Charge Code |
1730123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CLONAZEPAM 1 MG TABLET [9638]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 60687-555-11
|
| Hospital Charge Code |
1730123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| 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: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
CLONAZEPAM 2 MG TABLET [9639]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 16729-138-00
|
| Hospital Charge Code |
1730121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
CLONAZEPAM 2 MG TABLET [9639]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 16729-138-00
|
| Hospital Charge Code |
1730121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
CLONAZEPAM ORAL SUSPENSION COMPOUND 0.1 MG/ML [4080257]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 9994-0802-57
|
| Hospital Charge Code |
1715277
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.00
|
| Rate for Payer: Dignity Health Senior |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Senior |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1.00
|
|
|
CLONAZEPAM ORAL SUSPENSION COMPOUND 0.1 MG/ML [4080257]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 9994-0802-57
|
| Hospital Charge Code |
1715277
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]
|
Facility
|
OP
|
$15.92
|
|
|
Service Code
|
NDC 51862-453-04
|
| Hospital Charge Code |
1743456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$13.53 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.94
|
| Rate for Payer: Blue Shield of California Commercial |
$9.89
|
| Rate for Payer: Blue Shield of California EPN |
$9.35
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.53
|
| Rate for Payer: Dignity Health Senior |
$13.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.85
|
| Rate for Payer: Heritage Provider Network Senior |
$9.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.37
|
| Rate for Payer: TriValley Medical Group Senior |
$6.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.53
|
| Rate for Payer: Vantage Medical Group Senior |
$13.53
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]
|
Facility
|
OP
|
$15.92
|
|
|
Service Code
|
NDC 51862-453-01
|
| Hospital Charge Code |
1743456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$13.53 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.94
|
| Rate for Payer: Blue Shield of California Commercial |
$9.89
|
| Rate for Payer: Blue Shield of California EPN |
$9.35
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.53
|
| Rate for Payer: Dignity Health Senior |
$13.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.85
|
| Rate for Payer: Heritage Provider Network Senior |
$9.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.37
|
| Rate for Payer: TriValley Medical Group Senior |
$6.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.53
|
| Rate for Payer: Vantage Medical Group Senior |
$13.53
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]
|
Facility
|
IP
|
$15.92
|
|
|
Service Code
|
NDC 51862-453-01
|
| Hospital Charge Code |
1743456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$11.94 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.94
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.78
|
| Rate for Payer: Heritage Provider Network Senior |
$10.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.94
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]
|
Facility
|
IP
|
$15.92
|
|
|
Service Code
|
NDC 51862-453-04
|
| Hospital Charge Code |
1743456
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$11.94 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.94
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.78
|
| Rate for Payer: Heritage Provider Network Senior |
$10.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.94
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [27506]
|
Facility
|
OP
|
$26.80
|
|
|
Service Code
|
NDC 51862-454-04
|
| Hospital Charge Code |
1743457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$22.78 |
| Rate for Payer: Adventist Health Commercial |
$5.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.10
|
| Rate for Payer: Blue Shield of California Commercial |
$16.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.73
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.78
|
| Rate for Payer: Dignity Health Senior |
$22.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.59
|
| Rate for Payer: Heritage Provider Network Senior |
$16.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$20.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.72
|
| Rate for Payer: TriValley Medical Group Senior |
$10.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.78
|
| Rate for Payer: Vantage Medical Group Senior |
$22.78
|
|
