|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 2930013701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 5107930120
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| 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
|
$0.19
|
|
|
Service Code
|
NDC 5107930120
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.12
|
| 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 Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
CLONIDINE HCL 0.3 MG TABLET [1757]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 6233205631
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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 Foundation Hospitals 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 0228212910
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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 Foundation Hospitals 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
|
$0.13
|
|
|
Service Code
|
NDC 2930013701
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.08
|
| 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 Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
CLONIDINE HCL ER 0.1 MG TABLET,EXTENDED RELEASE,12 HR [107665]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 2724110806
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.45
|
| 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 Foundation Hospitals Commercial |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1.45
|
|
|
CLONIDINE HCL ER 0.1 MG TABLET,EXTENDED RELEASE,12 HR [107665]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 2724110806
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: Cash Price |
$0.76
|
| 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 Foundation Hospitals Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.27
|
|
|
CLONIDINE ORAL SUSPENSION COMPOUND 20 MCG/ML [4080258]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994080258
|
| Hospital Charge Code |
901700029
|
|
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: 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| 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: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$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 9994080258
|
| Hospital Charge Code |
901700029
|
|
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 Foundation Hospitals 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
|
HCPCS J0735
|
| Hospital Charge Code |
901700025
|
|
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 |
$13.52
|
| 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 |
$9.72
|
| Rate for Payer: Heritage Provider Network Senior |
$9.72
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$7.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.95
|
|
|
CLONIDINE (PF) 5,000 MCG/10 ML EPIDURAL SOLUTION [27113]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$117.37 |
| Rate for Payer: Adventist Health Commercial |
$4.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.37
|
| Rate for Payer: Blue Shield of California Commercial |
$33.15
|
| Rate for Payer: Blue Shield of California EPN |
$33.15
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$10.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.70
|
| Rate for Payer: Multiplan Commercial |
$15.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.40
|
| Rate for Payer: TriValley Medical Group Senior |
$8.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.85
|
| 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
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 5026818411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.79
|
| 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 |
$4.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California EPN |
$4.57
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.09
|
| 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: EPIC Health Plan Commercial |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.75
|
| Rate for Payer: TriValley Medical Group Senior |
$3.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$11.52
|
|
|
Service Code
|
NDC 6808475219
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$7.12
|
| 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 |
$5.76
|
| Rate for Payer: Blue Shield of California Commercial |
$7.03
|
| Rate for Payer: Blue Shield of California EPN |
$5.62
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.61
|
| Rate for Payer: TriValley Medical Group Senior |
$4.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$11.52
|
|
|
Service Code
|
NDC 6808475219
|
| Hospital Charge Code |
901700029
|
|
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 |
$7.42
|
| 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 Foundation Hospitals 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
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 5026818412
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.79
|
| 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 |
$4.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5.72
|
| Rate for Payer: Blue Shield of California EPN |
$4.57
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.09
|
| 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: EPIC Health Plan Commercial |
$6.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.80
|
| Rate for Payer: Heritage Provider Network Senior |
$5.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.75
|
| Rate for Payer: TriValley Medical Group Senior |
$3.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$9.37
|
|
|
Service Code
|
NDC 5026818411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.03 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.03
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Senior |
$6.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 5026818412
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.03 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.03
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Senior |
$6.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.03
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 0904646707
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$9.85
|
| 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 |
$7.97
|
| Rate for Payer: Blue Shield of California Commercial |
$9.72
|
| Rate for Payer: Blue Shield of California EPN |
$7.78
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$7.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.16
|
| Rate for Payer: Multiplan Commercial |
$11.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.38
|
| Rate for Payer: TriValley Medical Group Senior |
$6.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 300 MG TABLET [89346]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 0904646707
|
| Hospital Charge Code |
901700029
|
|
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 |
$10.27
|
| 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 Foundation Hospitals Medi-Cal |
$2.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.96
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0378362793
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| 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 Foundation Hospitals 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
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 7220519990
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
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 Non-Gatekeeper |
$0.12
|
| 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 |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| 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: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.20
|
|
|
Service Code
|
NDC 5511119630
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.13
|
| 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 Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
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 Non-Gatekeeper |
$0.04
|
| 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: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/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: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
