|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 29300-137-01
|
| Hospital Charge Code |
1711466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 51079-301-01
|
| Hospital Charge Code |
1711466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 0228-2129-10
|
| Hospital Charge Code |
1711466
|
|
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
|
|
|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 62332-056-31
|
| Hospital Charge Code |
1711466
|
|
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
|
|
|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 51079-301-20
|
| Hospital Charge Code |
1711466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
CLONIDINE HCL ER 0.1 MG TABLET,EXTENDED RELEASE,12 HR [107665]
|
Facility
OP
|
$1.70
|
|
|
Service Code
|
NDC 27241-108-06
|
| Hospital Charge Code |
ERX107665
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
CLONIDINE HCL ER 0.1 MG TABLET,EXTENDED RELEASE,12 HR [107665]
|
Facility
IP
|
$1.70
|
|
|
Service Code
|
NDC 27241-108-06
|
| Hospital Charge Code |
ERX107665
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
CLONIDINE ORAL SUSPENSION COMPOUND 20 MCG/ML [4080258]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0802-58
|
| Hospital Charge Code |
1715208
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
CLONIDINE ORAL SUSPENSION COMPOUND 20 MCG/ML [4080258]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0802-58
|
| Hospital Charge Code |
1715208
|
|
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
|
|
|
CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION [27113]
|
Facility
IP
|
$21.00
|
|
|
Service Code
|
CPT J0735
|
| Hospital Charge Code |
NDG27113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Adventist Health Commercial |
$4.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.43
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.22
|
| Rate for Payer: Heritage Provider Network Senior |
$14.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$15.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.02
|
|
|
CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION [27113]
|
Facility
OP
|
$21.00
|
|
|
Service Code
|
CPT J0735
|
| Hospital Charge Code |
NDG27113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$103.47 |
| Rate for Payer: Adventist Health Commercial |
$4.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$103.47
|
| Rate for Payer: Blue Shield of California Commercial |
$26.99
|
| Rate for Payer: Blue Shield of California EPN |
$26.99
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.85
|
| Rate for Payer: Dignity Health Senior |
$17.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.72
|
| Rate for Payer: Heritage Provider Network Senior |
$9.72
|
| Rate for Payer: IEHP Medi-Cal |
$37.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$15.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.85
|
| Rate for Payer: Vantage Medical Group Senior |
$17.85
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
IP
|
$11.52
|
|
|
Service Code
|
NDC 68084-752-19
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.91
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.80
|
| Rate for Payer: Heritage Provider Network Senior |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
IP
|
$11.49
|
|
|
Service Code
|
NDC 50268-184-12
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.78
|
| Rate for Payer: Heritage Provider Network Senior |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
OP
|
$15.94
|
|
|
Service Code
|
NDC 0904-6467-07
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.96
|
| Rate for Payer: Blue Shield of California Commercial |
$9.90
|
| Rate for Payer: Blue Shield of California EPN |
$9.36
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.55
|
| Rate for Payer: Dignity Health Senior |
$13.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.87
|
| Rate for Payer: Heritage Provider Network Senior |
$9.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.55
|
| Rate for Payer: Vantage Medical Group Senior |
$13.55
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
IP
|
$15.94
|
|
|
Service Code
|
NDC 0904-6467-07
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$11.96 |
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.95
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.79
|
| Rate for Payer: Heritage Provider Network Senior |
$10.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.96
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
IP
|
$11.49
|
|
|
Service Code
|
NDC 50268-184-11
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.78
|
| Rate for Payer: Heritage Provider Network Senior |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
OP
|
$11.52
|
|
|
Service Code
|
NDC 68084-752-19
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Blue Shield of California Commercial |
$7.15
|
| Rate for Payer: Blue Shield of California EPN |
$6.76
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: Dignity Health Senior |
$9.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Senior |
$7.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| 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
|
$11.49
|
|
|
Service Code
|
NDC 50268-184-12
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Blue Shield of California Commercial |
$7.14
|
| Rate for Payer: Blue Shield of California EPN |
$6.74
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.77
|
| Rate for Payer: Dignity Health Senior |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.11
|
| Rate for Payer: Heritage Provider Network Senior |
$7.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Vantage Medical Group Senior |
$9.77
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
OP
|
$11.49
|
|
|
Service Code
|
NDC 50268-184-11
|
| Hospital Charge Code |
1711988
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Blue Shield of California Commercial |
$7.14
|
| Rate for Payer: Blue Shield of California EPN |
$6.74
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.77
|
| Rate for Payer: Dignity Health Senior |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.11
|
| Rate for Payer: Heritage Provider Network Senior |
$7.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Vantage Medical Group Senior |
$9.77
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
IP
|
$0.31
|
|
|
Service Code
|
NDC 68084-536-01
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 0378-3627-93
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| 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
OP
|
$0.28
|
|
|
Service Code
|
NDC 0904-6294-61
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
OP
|
$0.31
|
|
|
Service Code
|
NDC 68084-536-11
|
| Hospital Charge Code |
1711725
|
|
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 Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| 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
|
$0.11
|
|
|
Service Code
|
NDC 16729-218-10
|
| Hospital Charge Code |
1711725
|
|
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 Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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
|
$0.20
|
|
|
Service Code
|
NDC 65862-357-30
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
