|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION [9080]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 59651-026-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0781-6104-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 65862-534-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 65862-534-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0781-6104-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0143-9982-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 65862-534-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 65862-534-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [33230]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0143-9982-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 65862-017-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 60687-787-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.63
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0093-3109-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
IP
|
$2.71
|
|
|
Service Code
|
NDC 60687-787-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 60687-787-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.63
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 65862-017-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
IP
|
$2.71
|
|
|
Service Code
|
NDC 60687-787-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$2.03
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 81964-205-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 81964-205-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 0781-2613-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0093-3109-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
AMOXICILLIN 500 MG CAPSULE [451]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 0781-2613-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 0781-1831-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
NDC 60687-792-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
NDC 60687-792-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.06
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
NDC 60687-792-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.06
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
|
