|
CLINDAMYCIN 1% TOP GEL 30GM EMP
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 7.3473E+10
|
| Hospital Charge Code |
2627028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$17.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$14.80
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$17.85
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$9.00
|
|
|
CLINDAMYCIN 1% TOP GEL 30GM EMP
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 7.3473E+10
|
| Hospital Charge Code |
2627028
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$22.50
|
|
|
CLINDAMYCIN 2% VAG CRM 40GM EMP
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
NDC 168027740
|
| Hospital Charge Code |
2622985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.32 |
| Max. Negotiated Rate |
$62.12 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$51.50
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$62.12
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.03
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$31.32
|
|
|
CLINDAMYCIN 2% VAG CRM 40GM EMP
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
NDC 168027740
|
| Hospital Charge Code |
2622985
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$78.30
|
|
|
CLINDAMYCIN 300MG CAP EMP
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 4.2571E+10
|
| Hospital Charge Code |
2626759
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$25.20
|
|
|
CLINDAMYCIN 300MG CAP EMP
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 4.2571E+10
|
| Hospital Charge Code |
2626759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$19.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$16.58
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$19.99
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$10.08
|
|
|
CLINDAMYCIN (CLEOCIN) 150MG CAP
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 591570801
|
| Hospital Charge Code |
2654605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$19.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$16.58
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$19.99
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$10.08
|
|
|
CLINDAMYCIN (CLEOCIN) 150MG CAP
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 591570801
|
| Hospital Charge Code |
2654605
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$25.20
|
|
|
CLINDAMYCIN (CLEOCIN) 300MG CAP
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 93525601
|
| Hospital Charge Code |
2626394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$13.57 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.25
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$13.57
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$6.84
|
|
|
CLINDAMYCIN (CLEOCIN) 300MG CAP
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 93525601
|
| Hospital Charge Code |
2626394
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$17.10
|
|
|
CLINDAMYCIN (CLEOCIN) 300MG INJ 2ML
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
NDC 9087021
|
| Hospital Charge Code |
2654610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$139.94 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$116.03
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$139.94
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$130.73
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$70.56
|
|
|
CLINDAMYCIN (CLEOCIN) 300MG INJ 2ML
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
NDC 9087021
|
| Hospital Charge Code |
2654610
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$176.40
|
|
|
CLINDAMYCIN (CLEOCIN) 600MG INJ 4ML
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
NDC 9077520
|
| Hospital Charge Code |
2626232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$139.94 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$116.03
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$139.94
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$130.73
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$70.56
|
|
|
CLINDAMYCIN (CLEOCIN) 600MG INJ 4ML
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
NDC 9077520
|
| Hospital Charge Code |
2626232
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$176.40
|
|
|
CLINDAMYCIN (CLEOCIN) 900MG INJ 6ML
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
NDC 7.2611E+10
|
| Hospital Charge Code |
2624811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$139.94 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$116.03
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$139.94
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$130.73
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$70.56
|
|
|
CLINDAMYCIN (CLEOCIN) 900MG INJ 6ML
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
NDC 7.2611E+10
|
| Hospital Charge Code |
2624811
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$176.40
|
|
|
CLINDAMYCIN/DEXTROSE 300MG/50ML PREMIX
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
NDC 781328809
|
| Hospital Charge Code |
2624891
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$186.30
|
|
|
CLINDAMYCIN/DEXTROSE 300MG/50ML PREMIX
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
NDC 781328809
|
| Hospital Charge Code |
2624891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.52 |
| Max. Negotiated Rate |
$147.80 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$122.54
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$147.80
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$138.07
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$74.52
|
|
|
CLINDAMYCIN/DEXTROSE 600MG/50ML PREMIX
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
NDC 781328909
|
| Hospital Charge Code |
2624892
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.20 |
| Max. Negotiated Rate |
$157.08 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$130.24
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$157.08
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$146.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$79.20
|
|
|
CLINDAMYCIN/DEXTROSE 600MG/50ML PREMIX
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
NDC 781328909
|
| Hospital Charge Code |
2624892
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$198.00
|
|
|
CLINDAMYCIN IVPB
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
HCPCS J2400
|
| Hospital Charge Code |
2058088
|
|
Hospital Revenue Code
|
370
|
| Rate for Payer: Cash Price |
$210.60
|
|
|
CLINDAMYCIN IVPB
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
HCPCS J2400
|
| Hospital Charge Code |
2058088
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$84.24 |
| Max. Negotiated Rate |
$167.08 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$138.53
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$167.08
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.08
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$84.24
|
|
|
CL- INFLUENZA FLUBLOK
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS 90682
|
| Hospital Charge Code |
5490682
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$64.26 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$53.28
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$64.26
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.03
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$32.40
|
|
|
CL- INFLUENZA FLUBLOK
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS 90682
|
| Hospital Charge Code |
5490682
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.03 |
| Max. Negotiated Rate |
$60.03 |
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.03
|
|
|
CL- INFLUENZA PEDIATRIC
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
HCPCS 90460
|
| Hospital Charge Code |
5490460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.69 |
| Max. Negotiated Rate |
$46.69 |
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$46.69
|
|
