|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 5167240421
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET [1759]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 7095415930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.97
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
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
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,068.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,543.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,929.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,378.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,274.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27252
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,068.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,543.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,929.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,378.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,274.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,731.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,298.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 28635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,068.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,543.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,929.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,378.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,274.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27266
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,068.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,543.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,929.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,378.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,274.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 27818
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,068.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,543.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,929.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,378.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,274.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,731.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,298.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 0054414622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
NDC 0574010770
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Vantage Medical Group Senior |
$1.31
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
NDC 0574010770
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 0054414622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0054814622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Senior |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Vantage Medical Group Senior |
$2.81
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0054814622
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.13
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$2.08
|
|
|
Service Code
|
NDC 0054414623
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$2.08
|
|
|
Service Code
|
NDC 0054414623
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.04
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.83
|
| Rate for Payer: TriValley Medical Group Senior |
$0.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Vantage Medical Group Senior |
$1.77
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 4580243411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| 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 |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| 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 |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [1767]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 4580243411
|
| 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 |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| 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
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 1013567181
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Vantage Medical Group Senior |
$1.38
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
NDC 7139905001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Senior |
$1.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 1013567181
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION [1768]
|
Facility
|
IP
|
$1.63
|
|
|
Service Code
|
NDC 7139905001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 5167220036
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.07
|
| 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 Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 5167220036
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.05
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 5167220620
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
CLOTRIMAZOLE 2 % VAGINAL CREAM [33986]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 2438511009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
