|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
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 |
$0.27 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
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 |
$0.27 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
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 |
$0.27 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.84
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other HMO |
$0.68
|
| Rate for Payer: United Healthcare HMO Rider |
$0.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
|
|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
|
|
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 |
$1.61 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Adventist Health Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California Commercial |
$5.93
|
| Rate for Payer: Blue Shield of California EPN |
$3.91
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Cigna of CA HMO |
$5.63
|
| Rate for Payer: Cigna of CA PPO |
$5.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.22
|
| Rate for Payer: EPIC Health Plan Senior |
$3.22
|
| Rate for Payer: Galaxy Health WC |
$6.83
|
| Rate for Payer: Global Benefits Group Commercial |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$6.43
|
| Rate for Payer: Networks By Design Commercial |
$5.23
|
| Rate for Payer: Prime Health Services Commercial |
$6.83
|
|
|
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 |
$1.62 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.97
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Other HMO |
$4.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 0781-1943-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$5.97
|
| Rate for Payer: Blue Shield of California EPN |
$3.93
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Adventist Health Commercial |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$4.94
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna of CA HMO |
$4.69
|
| Rate for Payer: Cigna of CA PPO |
$4.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.68
|
| Rate for Payer: EPIC Health Plan Senior |
$2.68
|
| Rate for Payer: Galaxy Health WC |
$5.70
|
| Rate for Payer: Global Benefits Group Commercial |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Networks By Design Commercial |
$4.36
|
| Rate for Payer: Prime Health Services Commercial |
$5.70
|
|
|
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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Multiplan Commercial |
$6.43
|
| Rate for Payer: Networks By Design Commercial |
$5.23
|
| Rate for Payer: Prime Health Services Commercial |
$6.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.02
|
| Rate for Payer: United Healthcare All Other HMO |
$4.02
|
| Rate for Payer: United Healthcare HMO Rider |
$4.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.83
|
| Rate for Payer: Vantage Medical Group Senior |
$6.83
|
| Rate for Payer: Adventist Health Commercial |
$1.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.94
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Cigna of CA HMO |
$5.63
|
| Rate for Payer: Cigna of CA PPO |
$5.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.22
|
| Rate for Payer: EPIC Health Plan Senior |
$3.22
|
| Rate for Payer: Galaxy Health WC |
$6.83
|
| Rate for Payer: Global Benefits Group Commercial |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.63
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 0781-1943-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.97
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Other HMO |
$4.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 0781-1943-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$5.97
|
| Rate for Payer: Blue Shield of California EPN |
$3.93
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
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 |
$1.34 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Adventist Health Commercial |
$1.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.11
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna of CA HMO |
$4.69
|
| Rate for Payer: Cigna of CA PPO |
$4.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.68
|
| Rate for Payer: EPIC Health Plan Senior |
$2.68
|
| Rate for Payer: Galaxy Health WC |
$5.70
|
| Rate for Payer: Global Benefits Group Commercial |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.69
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Networks By Design Commercial |
$4.36
|
| Rate for Payer: Prime Health Services Commercial |
$5.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.35
|
| Rate for Payer: United Healthcare All Other HMO |
$3.35
|
| Rate for Payer: United Healthcare HMO Rider |
$3.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5.70
|
|
|
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [464]
|
Facility
|
IP
|
$57.60
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Adventist Health Commercial |
$11.52
|
| Rate for Payer: Blue Shield of California Commercial |
$42.51
|
| Rate for Payer: Blue Shield of California EPN |
$27.99
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$40.32
|
| Rate for Payer: Cigna of CA PPO |
$40.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: EPIC Health Plan Senior |
$23.04
|
| Rate for Payer: Galaxy Health WC |
$48.96
|
| Rate for Payer: Global Benefits Group Commercial |
$34.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$38.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.82
|
| Rate for Payer: Multiplan Commercial |
$46.08
|
| Rate for Payer: Networks By Design Commercial |
$28.80
|
| Rate for Payer: Prime Health Services Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.62
|
| Rate for Payer: United Healthcare All Other HMO |
$21.04
|
| Rate for Payer: United Healthcare HMO Rider |
$20.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.86
|
|
|
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [464]
|
Facility
|
OP
|
$57.60
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$135.82 |
| Rate for Payer: Galaxy Health WC |
$48.96
|
| Rate for Payer: Global Benefits Group Commercial |
$34.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$38.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$40.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$40.32
|
| Rate for Payer: Multiplan Commercial |
$46.08
|
| Rate for Payer: Networks By Design Commercial |
$28.80
|
| Rate for Payer: Prime Health Services Commercial |
$48.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$34.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$34.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.62
|
| Rate for Payer: United Healthcare All Other HMO |
$21.04
|
| Rate for Payer: United Healthcare HMO Rider |
$20.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.96
|
| Rate for Payer: Vantage Medical Group Senior |
$48.96
|
| Rate for Payer: Adventist Health Commercial |
$11.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$37.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$135.82
|
| Rate for Payer: Blue Shield of California Commercial |
$60.00
|
| Rate for Payer: Blue Shield of California EPN |
$60.00
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$40.32
|
| Rate for Payer: Cigna of CA PPO |
$40.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: EPIC Health Plan Senior |
$23.04
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
OP
|
$381.97
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$324.67 |
| Rate for Payer: Adventist Health Commercial |
$76.39
|
| Rate for Payer: Adventist Health Commercial |
$57.29
|
| Rate for Payer: Adventist Health Commercial |
$61.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$187.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$250.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$200.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.40
|
| Rate for Payer: Blue Shield of California Commercial |
$61.14
|
| Rate for Payer: Blue Shield of California Commercial |
$61.14
|
| Rate for Payer: Blue Shield of California Commercial |
$61.14
|
| Rate for Payer: Blue Shield of California EPN |
$61.14
|
| Rate for Payer: Blue Shield of California EPN |
$61.14
|
| Rate for Payer: Blue Shield of California EPN |
$61.14
|
| Rate for Payer: Cash Price |
$157.54
|
| Rate for Payer: Cash Price |
$168.14
|
| Rate for Payer: Cash Price |
$168.14
|
| Rate for Payer: Cash Price |
$157.54
|
| Rate for Payer: Cash Price |
$210.08
|
| Rate for Payer: Cash Price |
$210.08
|
| Rate for Payer: Cigna of CA HMO |
$213.99
|
| Rate for Payer: Cigna of CA HMO |
$200.51
|
| Rate for Payer: Cigna of CA HMO |
$267.38
|
| Rate for Payer: Cigna of CA PPO |
$200.51
|
| Rate for Payer: Cigna of CA PPO |
$213.99
|
| Rate for Payer: Cigna of CA PPO |
$267.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.54
|
| Rate for Payer: EPIC Health Plan Senior |
$22.62
|
| Rate for Payer: EPIC Health Plan Senior |
$22.62
|
| Rate for Payer: EPIC Health Plan Senior |
$22.62
|
| Rate for Payer: Galaxy Health WC |
$324.67
|
| Rate for Payer: Galaxy Health WC |
$243.47
|
| Rate for Payer: Galaxy Health WC |
$259.85
|
| Rate for Payer: Global Benefits Group Commercial |
$229.18
|
| Rate for Payer: Global Benefits Group Commercial |
$183.42
|
| Rate for Payer: Global Benefits Group Commercial |
$171.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.31
|
| Rate for Payer: Multiplan Commercial |
$229.15
|
| Rate for Payer: Multiplan Commercial |
$244.56
|
| Rate for Payer: Multiplan Commercial |
$305.58
|
| Rate for Payer: Networks By Design Commercial |
$143.22
|
| Rate for Payer: Networks By Design Commercial |
$152.85
|
| Rate for Payer: Networks By Design Commercial |
$190.99
|
| Rate for Payer: Prime Health Services Commercial |
$259.85
|
| Rate for Payer: Prime Health Services Commercial |
$324.67
|
| Rate for Payer: Prime Health Services Commercial |
$243.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$183.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$229.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$171.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$229.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$183.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$171.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$107.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.35
|
| Rate for Payer: United Healthcare All Other HMO |
$104.64
|
| Rate for Payer: United Healthcare All Other HMO |
$139.53
|
| Rate for Payer: United Healthcare All Other HMO |
$111.67
|
| Rate for Payer: United Healthcare HMO Rider |
$109.26
|
| Rate for Payer: United Healthcare HMO Rider |
$102.37
|
| Rate for Payer: United Healthcare HMO Rider |
$136.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$100.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$93.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$125.10
|
| Rate for Payer: Upland Medical Group Pediatric |
$22.62
|
| Rate for Payer: Upland Medical Group Pediatric |
$22.62
|
| Rate for Payer: Upland Medical Group Pediatric |
$22.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.88
|
| Rate for Payer: Vantage Medical Group Senior |
$24.88
|
| Rate for Payer: Vantage Medical Group Senior |
$24.88
|
| Rate for Payer: Vantage Medical Group Senior |
$24.88
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
IP
|
$286.44
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.29 |
| Max. Negotiated Rate |
$243.47 |
| Rate for Payer: Adventist Health Commercial |
$57.29
|
| Rate for Payer: Adventist Health Commercial |
$61.14
|
| Rate for Payer: Adventist Health Commercial |
$76.39
|
| Rate for Payer: Blue Shield of California Commercial |
$225.61
|
| Rate for Payer: Blue Shield of California Commercial |
$281.89
|
| Rate for Payer: Blue Shield of California Commercial |
$211.39
|
| Rate for Payer: Blue Shield of California EPN |
$148.57
|
| Rate for Payer: Blue Shield of California EPN |
$139.21
|
| Rate for Payer: Blue Shield of California EPN |
$185.64
|
| Rate for Payer: Cash Price |
$168.14
|
| Rate for Payer: Cash Price |
$157.54
|
| Rate for Payer: Cash Price |
$210.08
|
| Rate for Payer: Cigna of CA HMO |
$213.99
|
| Rate for Payer: Cigna of CA HMO |
$200.51
|
| Rate for Payer: Cigna of CA HMO |
$267.38
|
| Rate for Payer: Cigna of CA PPO |
$213.99
|
| Rate for Payer: Cigna of CA PPO |
$200.51
|
| Rate for Payer: Cigna of CA PPO |
$267.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.79
|
| Rate for Payer: EPIC Health Plan Senior |
$152.79
|
| Rate for Payer: EPIC Health Plan Senior |
$114.58
|
| Rate for Payer: EPIC Health Plan Senior |
$122.28
|
| Rate for Payer: Galaxy Health WC |
$259.85
|
| Rate for Payer: Galaxy Health WC |
$243.47
|
| Rate for Payer: Galaxy Health WC |
$324.67
|
| Rate for Payer: Global Benefits Group Commercial |
$229.18
|
| Rate for Payer: Global Benefits Group Commercial |
$171.86
|
| Rate for Payer: Global Benefits Group Commercial |
$183.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$191.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$109.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$145.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$189.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$177.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$236.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.67
|
| Rate for Payer: Multiplan Commercial |
$229.15
|
| Rate for Payer: Multiplan Commercial |
$244.56
|
| Rate for Payer: Multiplan Commercial |
$305.58
|
| Rate for Payer: Networks By Design Commercial |
$152.85
|
| Rate for Payer: Networks By Design Commercial |
$190.99
|
| Rate for Payer: Networks By Design Commercial |
$143.22
|
| Rate for Payer: Prime Health Services Commercial |
$243.47
|
| Rate for Payer: Prime Health Services Commercial |
$259.85
|
| Rate for Payer: Prime Health Services Commercial |
$324.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$107.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.35
|
| Rate for Payer: United Healthcare All Other HMO |
$139.53
|
| Rate for Payer: United Healthcare All Other HMO |
$104.64
|
| Rate for Payer: United Healthcare All Other HMO |
$111.67
|
| Rate for Payer: United Healthcare HMO Rider |
$109.26
|
| Rate for Payer: United Healthcare HMO Rider |
$136.52
|
| Rate for Payer: United Healthcare HMO Rider |
$102.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$125.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$93.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$100.12
|
|
|
AMPHOTERICIN ORAL SUSPENSION COMPOUND 5 MG/ML [4080241]
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 9994-0802-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$3.37
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cigna of CA HMO |
$3.19
|
| Rate for Payer: Cigna of CA PPO |
$3.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Senior |
$1.82
|
| Rate for Payer: Galaxy Health WC |
$3.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Prime Health Services Commercial |
$3.88
|
|
|
AMPHOTERICIN ORAL SUSPENSION COMPOUND 5 MG/ML [4080241]
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 9994-0802-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.80
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cigna of CA HMO |
$3.19
|
| Rate for Payer: Cigna of CA PPO |
$3.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Senior |
$1.82
|
| Rate for Payer: Galaxy Health WC |
$3.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.19
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Prime Health Services Commercial |
$3.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.28
|
| Rate for Payer: United Healthcare All Other HMO |
$2.28
|
| Rate for Payer: United Healthcare HMO Rider |
$2.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.88
|
| Rate for Payer: Vantage Medical Group Senior |
$3.88
|
|
