|
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
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 65862-502-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
IP
|
$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: 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
|
$0.53
|
|
|
Service Code
|
NDC 65862-502-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
NDC 0781-1831-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$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
|
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
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
AMOXICILLIN 500 MG TABLET [17456]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 65862-014-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
AMOXICILLIN 500 MG TABLET [17456]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 65862-014-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 42571-162-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.82
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 42571-162-42
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 65862-503-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 42571-162-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 65862-503-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 65862-503-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 65862-503-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.82
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 42571-162-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 0781-1943-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.85
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$8.04
|
|
|
Service Code
|
NDC 43598-020-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$6.03
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$6.70
|
|
|
Service Code
|
NDC 43598-220-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.02
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.69
|
| Rate for Payer: Multiplan Commercial |
$5.03
|
|
