|
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
|
$0.11
|
|
|
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
|
$0.11
|
|
|
Service Code
|
NDC 16729-218-10
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| 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 Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
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
IP
|
$0.28
|
|
|
Service Code
|
NDC 0904-6294-61
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| 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 Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
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
IP
|
$0.64
|
|
|
Service Code
|
NDC 0378-3627-93
|
| Hospital Charge Code |
1711725
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| 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
|
|
|
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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
IP
|
$15.94
|
|
|
Service Code
|
NDC 9994-0802-59
|
| Hospital Charge Code |
1715269
|
|
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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080259]
|
Facility
OP
|
$15.94
|
|
|
Service Code
|
NDC 9994-0802-59
|
| Hospital Charge Code |
1715269
|
|
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
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
OP
|
$5.23
|
|
|
Service Code
|
NDC 51672-4044-1
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.45
|
| Rate for Payer: Dignity Health Senior |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Senior |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Vantage Medical Group Senior |
$4.45
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
IP
|
$2.75
|
|
|
Service Code
|
NDC 0378-0070-01
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
IP
|
$5.23
|
|
|
Service Code
|
NDC 51672-4044-1
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.59
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.54
|
| Rate for Payer: Heritage Provider Network Senior |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
CLORAZEPATE DIPOTASSIUM 15 MG TABLET [1758]
|
Facility
OP
|
$2.75
|
|
|
Service Code
|
NDC 0378-0070-01
|
| Hospital Charge Code |
1730084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Senior |
$2.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
OP
|
$1.19
|
|
|
Service Code
|
NDC 9999-4081-86
|
| Hospital Charge Code |
ERX408186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Senior |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 1.875 MG 1/2 TAB [408186]
|
Facility
IP
|
$1.19
|
|
|
Service Code
|
NDC 9999-4081-86
|
| Hospital Charge Code |
ERX408186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
IP
|
$1.19
|
|
|
Service Code
|
NDC 13107-319-01
|
| Hospital Charge Code |
1730086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
OP
|
$1.19
|
|
|
Service Code
|
NDC 13107-319-01
|
| Hospital Charge Code |
1730086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Senior |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 25605
|
| Min. Negotiated Rate |
$423.40 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: Dignity Health Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,008.09
|
| Rate for Payer: Humana Medicare |
$2,008.09
|
| Rate for Payer: IEHP Medi-Cal |
$423.40
|
| Rate for Payer: IEHP Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,815.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,369.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,530.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,208.90
|
| Rate for Payer: TriValley Medical Group Senior |
$2,008.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
Closed treatment of distal radioulnar dislocation with manipulation
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 25675
|
| Min. Negotiated Rate |
$294.64 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$294.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$441.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$324.10
|
| Rate for Payer: Dignity Health Senior |
$294.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$294.64
|
| Rate for Payer: Humana Medicare |
$294.64
|
| Rate for Payer: IEHP Medi-Cal |
$358.35
|
| Rate for Payer: IEHP Medicare Advantage |
$294.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$559.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$347.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$371.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$371.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$324.10
|
| Rate for Payer: TriValley Medical Group Senior |
$294.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$441.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.10
|
| Rate for Payer: Vantage Medical Group Senior |
$294.64
|
|
|
Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27825
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: Dignity Health Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,008.09
|
| Rate for Payer: Humana Medicare |
$2,008.09
|
| Rate for Payer: IEHP Medi-Cal |
$103.38
|
| Rate for Payer: IEHP Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,815.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,369.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,530.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,208.90
|
| Rate for Payer: TriValley Medical Group Senior |
$2,008.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
Closed treatment of mandibular fracture with interdental fixation
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21453
|
| Min. Negotiated Rate |
$526.19 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$526.19
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Closed treatment of nasal bone fracture with manipulation; without stabilization
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21315
|
| Min. Negotiated Rate |
$123.71 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: Dignity Health Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,905.44
|
| Rate for Payer: Humana Medicare |
$1,905.44
|
| Rate for Payer: IEHP Medi-Cal |
$123.71
|
| Rate for Payer: IEHP Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,620.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,248.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,400.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,095.98
|
| Rate for Payer: TriValley Medical Group Senior |
$1,905.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
|
Closed treatment of nasal bone fracture with manipulation; with stabilization
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21320
|
| Min. Negotiated Rate |
$197.46 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: IEHP Medi-Cal |
$197.46
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Closed treatment of nasal septal fracture, with or without stabilization
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21337
|
| Min. Negotiated Rate |
$203.86 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: IEHP Medi-Cal |
$203.86
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
