|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 42571-162-01
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.54 |
| 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 |
$0.32
|
| 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 Beech St/Commercial/PHCS |
$0.54
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-01
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 66685-1001-1
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.02
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$7.37
|
|
|
Service Code
|
NDC 0781-1943-82
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.42
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.53
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$7.37
|
|
|
Service Code
|
NDC 0781-1943-82
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$5.90 |
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.53
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$8.04
|
|
|
Service Code
|
NDC 43598-020-28
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$6.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.82
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.03
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$7.37
|
|
|
Service Code
|
NDC 0781-1943-39
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.42
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.53
|
|
|
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 |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$6.03
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$7.37
|
|
|
Service Code
|
NDC 0781-1943-39
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$5.90 |
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.53
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$6.70
|
|
|
Service Code
|
NDC 43598-220-28
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.02
|
|
|
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 |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$5.02 |
| 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 |
$3.02
|
| 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 |
$3.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.02
|
|
|
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [464]
|
Facility
|
OP
|
$52.44
|
|
|
Service Code
|
CPT J0285
|
| Hospital Charge Code |
1757256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.84 |
| Max. Negotiated Rate |
$39.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$31.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$31.46
|
| Rate for Payer: Cash Price |
$23.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$31.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$31.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$39.33
|
|
|
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [464]
|
Facility
|
IP
|
$52.44
|
|
|
Service Code
|
CPT J0285
|
| Hospital Charge Code |
1757256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.84 |
| Max. Negotiated Rate |
$41.95 |
| Rate for Payer: Cash Price |
$23.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$31.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$39.33
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
IP
|
$305.70
|
|
|
Service Code
|
NDC 55150-365-01
|
| Hospital Charge Code |
1757065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.14 |
| Max. Negotiated Rate |
$244.56 |
| Rate for Payer: Cash Price |
$137.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$244.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$183.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$229.28
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
OP
|
$360.05
|
|
|
Service Code
|
NDC 0469-3051-30
|
| Hospital Charge Code |
1757065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.03 |
| Max. Negotiated Rate |
$270.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$216.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$216.03
|
| Rate for Payer: Cash Price |
$162.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$216.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$216.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$198.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$270.04
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
IP
|
$360.05
|
|
|
Service Code
|
NDC 0469-3051-30
|
| Hospital Charge Code |
1757065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.03 |
| Max. Negotiated Rate |
$288.04 |
| Rate for Payer: Cash Price |
$162.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$288.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$216.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$198.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$270.04
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
OP
|
$305.70
|
|
|
Service Code
|
NDC 55150-365-01
|
| Hospital Charge Code |
1757065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.14 |
| Max. Negotiated Rate |
$229.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$183.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$183.42
|
| Rate for Payer: Cash Price |
$137.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$183.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$183.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$229.28
|
|
|
AMPHOTERICIN ORAL SUSPENSION COMPOUND 5 MG/ML [4080241]
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 9994-0802-41
|
| Hospital Charge Code |
1715157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.42
|
|
|
AMPHOTERICIN ORAL SUSPENSION COMPOUND 5 MG/ML [4080241]
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 9994-0802-41
|
| Hospital Charge Code |
1715157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.74
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.42
|
|
|
AMPICILLIN 10 GRAM SOLUTION FOR INJECTION [470]
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1752200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$37.25
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$66.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$54.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$49.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$62.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$58.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$67.50
|
|
|
AMPICILLIN 10 GRAM SOLUTION FOR INJECTION [470]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1752200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$67.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$54.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$46.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$49.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$54.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$49.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$46.80
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$37.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$54.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$49.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$46.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$54.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$49.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$67.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$62.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$58.50
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.98
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
AMPICILLIN 250 MG SOLUTION FOR INJECTION [473]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.44
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.66
|
|
|
AMPICILLIN 250 MG SOLUTION FOR INJECTION [473]
|
Facility
|
IP
|
$2.22
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
1720395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.66
|
|
