|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 65862-503-20
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| 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: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| 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 |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: BCBS Transplant Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Central Health Plan Commercial |
$1.09
|
| 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: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.02
|
| Rate for Payer: IEHP medi-cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: Riverside University Health MISP |
$0.54
|
| 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 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 42571-162-01
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: BCBS Transplant Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| 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: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.54
|
| Rate for Payer: IEHP medi-cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: Riverside University Health MISP |
$0.29
|
| 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 Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 65862-503-20
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| 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: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.33
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Riverside University Health MISP |
$0.18
|
| 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 Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
OP
|
$1.36
|
|
|
Service Code
|
NDC 66685-1001-1
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: BCBS Transplant Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Central Health Plan Commercial |
$1.09
|
| 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: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.02
|
| Rate for Payer: IEHP medi-cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: Riverside University Health MISP |
$0.54
|
| 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 Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
OP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-20
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: BCBS Transplant Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Central Health Plan Commercial |
$1.09
|
| 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: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.02
|
| Rate for Payer: IEHP medi-cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: Riverside University Health MISP |
$0.54
|
| 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 Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
IP
|
$1.36
|
|
|
Service Code
|
NDC 0781-1852-20
|
| Hospital Charge Code |
1711674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Central Health Plan Commercial |
$1.09
|
| 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: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
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 |
$1.47 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.94
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$5.16
|
| Rate for Payer: Cigna of CA PPO |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: Galaxy Health WC |
$6.26
|
| Rate for Payer: Global Benefits Group Commercial |
$4.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Networks By Design Commercial |
$4.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.26
|
|
|
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 |
$1.61 |
| Max. Negotiated Rate |
$7.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.42
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.75
|
| Rate for Payer: BCBS Transplant Transplant |
$4.82
|
| Rate for Payer: Blue Shield of California Commercial |
$5.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.93
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Central Health Plan Commercial |
$6.43
|
| 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: EPIC Health Plan Commercial |
$3.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.22
|
| Rate for Payer: Galaxy Health WC |
$6.83
|
| Rate for Payer: Global Benefits Group Commercial |
$4.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.03
|
| Rate for Payer: IEHP medi-cal |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$6.03
|
| Rate for Payer: Networks By Design Commercial |
$5.23
|
| Rate for Payer: Prime Health Services Commercial |
$6.83
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.82
|
| Rate for Payer: Riverside University Health MISP |
$3.22
|
| 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 Medi-Cal |
$6.83
|
| Rate for Payer: Vantage Medical Group Senior |
$6.83
|
|
|
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 |
$1.47 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.35
|
| Rate for Payer: BCBS Transplant Transplant |
$4.42
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$5.16
|
| Rate for Payer: Cigna of CA PPO |
$5.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.95
|
| Rate for Payer: Galaxy Health WC |
$6.26
|
| Rate for Payer: Global Benefits Group Commercial |
$4.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.53
|
| Rate for Payer: IEHP medi-cal |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Networks By Design Commercial |
$4.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.42
|
| Rate for Payer: Riverside University Health MISP |
$2.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.68
|
| Rate for Payer: United Healthcare All Other HMO |
$3.68
|
| Rate for Payer: United Healthcare HMO Rider |
$3.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.26
|
|
|
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 |
$1.47 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.35
|
| Rate for Payer: BCBS Transplant Transplant |
$4.42
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$5.16
|
| Rate for Payer: Cigna of CA PPO |
$5.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.95
|
| Rate for Payer: Galaxy Health WC |
$6.26
|
| Rate for Payer: Global Benefits Group Commercial |
$4.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.53
|
| Rate for Payer: IEHP medi-cal |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Networks By Design Commercial |
$4.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.42
|
| Rate for Payer: Riverside University Health MISP |
$2.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.68
|
| Rate for Payer: United Healthcare All Other HMO |
$3.68
|
| Rate for Payer: United Healthcare HMO Rider |
$3.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.26
|
|
|
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 |
$1.47 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.94
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Central Health Plan Commercial |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$5.16
|
| Rate for Payer: Cigna of CA PPO |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: Galaxy Health WC |
$6.26
|
| Rate for Payer: Global Benefits Group Commercial |
$4.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.47
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Networks By Design Commercial |
$4.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.26
|
|
|
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 |
$1.61 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Networks By Design Commercial |
$5.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6.03
|
| Rate for Payer: Blue Shield of California EPN |
$4.29
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Central Health Plan Commercial |
$6.43
|
| 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: Galaxy Health WC |
$6.83
|
| Rate for Payer: Global Benefits Group Commercial |
$4.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$6.03
|
| Rate for Payer: Prime Health Services Commercial |
$6.83
|
|
|
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 |
$1.34 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.02
|
| Rate for Payer: Blue Shield of California EPN |
$3.58
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Central Health Plan Commercial |
$5.36
|
| 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: Galaxy Health WC |
$5.70
|
| Rate for Payer: Global Benefits Group Commercial |
$4.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$5.02
|
| 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
|
$6.70
|
|
|
Service Code
|
NDC 43598-220-28
|
| Hospital Charge Code |
ERX33862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$6.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.96
|
| Rate for Payer: BCBS Transplant Transplant |
$4.02
|
| Rate for Payer: Blue Shield of California Commercial |
$4.21
|
| Rate for Payer: Blue Shield of California EPN |
$3.28
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Central Health Plan Commercial |
$5.36
|
| 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: EPIC Health Plan Commercial |
$2.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.68
|
| Rate for Payer: Galaxy Health WC |
$5.70
|
| Rate for Payer: Global Benefits Group Commercial |
$4.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.02
|
| Rate for Payer: IEHP medi-cal |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$5.02
|
| Rate for Payer: Networks By Design Commercial |
$4.36
|
| Rate for Payer: Prime Health Services Commercial |
$5.70
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.02
|
| Rate for Payer: Riverside University Health MISP |
$2.68
|
| 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 Medi-Cal |
$5.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5.70
|
|
|
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 |
$10.49 |
| Max. Negotiated Rate |
$59.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$59.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$44.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$28.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$28.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$31.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.69
|
| Rate for Payer: BCBS Transplant Transplant |
$31.46
|
| Rate for Payer: Blue Shield of California Commercial |
$57.68
|
| Rate for Payer: Blue Shield of California EPN |
$52.44
|
| Rate for Payer: Cash Price |
$23.60
|
| Rate for Payer: Cash Price |
$23.60
|
| Rate for Payer: Central Health Plan Commercial |
$41.95
|
| Rate for Payer: Cigna of CA HMO |
$36.71
|
| Rate for Payer: Cigna of CA PPO |
$36.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.98
|
| Rate for Payer: Galaxy Health WC |
$44.57
|
| Rate for Payer: Global Benefits Group Commercial |
$31.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$47.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$39.33
|
| Rate for Payer: IEHP medi-cal |
$46.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.49
|
| Rate for Payer: Multiplan Commercial |
$39.33
|
| Rate for Payer: Networks By Design Commercial |
$26.22
|
| Rate for Payer: Prime Health Services Commercial |
$44.57
|
| Rate for Payer: Riverside University Health MISP |
$20.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$26.22
|
| Rate for Payer: United Healthcare All Other HMO |
$26.22
|
| Rate for Payer: United Healthcare HMO Rider |
$26.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$26.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$44.57
|
| Rate for Payer: Vantage Medical Group Senior |
$44.57
|
|
|
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 |
$10.49 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$39.33
|
| Rate for Payer: Blue Shield of California EPN |
$28.00
|
| Rate for Payer: Cash Price |
$23.60
|
| Rate for Payer: Cash Price |
$23.60
|
| Rate for Payer: Central Health Plan Commercial |
$41.95
|
| Rate for Payer: Cigna of CA HMO |
$36.71
|
| Rate for Payer: Cigna of CA PPO |
$36.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.98
|
| Rate for Payer: Galaxy Health WC |
$44.57
|
| Rate for Payer: Global Benefits Group Commercial |
$31.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$47.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.49
|
| Rate for Payer: Multiplan Commercial |
$39.33
|
| Rate for Payer: Networks By Design Commercial |
$26.22
|
| Rate for Payer: Prime Health Services Commercial |
$44.57
|
|
|
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 |
$72.01 |
| Max. Negotiated Rate |
$324.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$218.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$306.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$198.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$198.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$174.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$212.72
|
| Rate for Payer: BCBS Transplant Transplant |
$216.03
|
| Rate for Payer: Blue Shield of California Commercial |
$226.47
|
| Rate for Payer: Blue Shield of California EPN |
$176.06
|
| Rate for Payer: Cash Price |
$162.02
|
| Rate for Payer: Cash Price |
$162.02
|
| Rate for Payer: Central Health Plan Commercial |
$288.04
|
| Rate for Payer: Cigna of CA HMO |
$252.04
|
| Rate for Payer: Cigna of CA PPO |
$252.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$306.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$144.02
|
| Rate for Payer: Galaxy Health WC |
$306.04
|
| Rate for Payer: Global Benefits Group Commercial |
$216.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$324.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$270.04
|
| Rate for Payer: IEHP medi-cal |
$126.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$240.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.01
|
| Rate for Payer: Multiplan Commercial |
$270.04
|
| Rate for Payer: Networks By Design Commercial |
$180.02
|
| Rate for Payer: Prime Health Services Commercial |
$306.04
|
| Rate for Payer: Riverside University Health MISP |
$144.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$216.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$216.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$180.02
|
| Rate for Payer: United Healthcare All Other HMO |
$180.02
|
| Rate for Payer: United Healthcare HMO Rider |
$180.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$180.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$306.04
|
| Rate for Payer: Vantage Medical Group Senior |
$306.04
|
|
|
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 |
$61.14 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$229.28
|
| Rate for Payer: Blue Shield of California EPN |
$163.24
|
| Rate for Payer: Cash Price |
$137.57
|
| Rate for Payer: Cash Price |
$137.57
|
| Rate for Payer: Central Health Plan Commercial |
$244.56
|
| Rate for Payer: Cigna of CA HMO |
$213.99
|
| Rate for Payer: Cigna of CA PPO |
$213.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$122.28
|
| Rate for Payer: Galaxy Health WC |
$259.84
|
| Rate for Payer: Global Benefits Group Commercial |
$183.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$275.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.14
|
| Rate for Payer: Multiplan Commercial |
$229.28
|
| Rate for Payer: Networks By Design Commercial |
$152.85
|
| Rate for Payer: Prime Health Services Commercial |
$259.84
|
|
|
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 |
$72.01 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$270.04
|
| Rate for Payer: Blue Shield of California EPN |
$192.27
|
| Rate for Payer: Cash Price |
$162.02
|
| Rate for Payer: Cash Price |
$162.02
|
| Rate for Payer: Central Health Plan Commercial |
$288.04
|
| Rate for Payer: Cigna of CA HMO |
$252.04
|
| Rate for Payer: Cigna of CA PPO |
$252.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$144.02
|
| Rate for Payer: Galaxy Health WC |
$306.04
|
| Rate for Payer: Global Benefits Group Commercial |
$216.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$324.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$240.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.01
|
| Rate for Payer: Multiplan Commercial |
$270.04
|
| Rate for Payer: Networks By Design Commercial |
$180.02
|
| Rate for Payer: Prime Health Services Commercial |
$306.04
|
|
|
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 |
$61.14 |
| Max. Negotiated Rate |
$275.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$185.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$259.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$168.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$168.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$148.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$180.61
|
| Rate for Payer: BCBS Transplant Transplant |
$183.42
|
| Rate for Payer: Blue Shield of California Commercial |
$192.29
|
| Rate for Payer: Blue Shield of California EPN |
$149.49
|
| Rate for Payer: Cash Price |
$137.57
|
| Rate for Payer: Cash Price |
$137.57
|
| Rate for Payer: Central Health Plan Commercial |
$244.56
|
| Rate for Payer: Cigna of CA HMO |
$213.99
|
| Rate for Payer: Cigna of CA PPO |
$213.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$122.28
|
| Rate for Payer: Galaxy Health WC |
$259.84
|
| Rate for Payer: Global Benefits Group Commercial |
$183.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$275.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$229.28
|
| Rate for Payer: IEHP medi-cal |
$107.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$203.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.14
|
| Rate for Payer: Multiplan Commercial |
$229.28
|
| Rate for Payer: Networks By Design Commercial |
$152.85
|
| Rate for Payer: Prime Health Services Commercial |
$259.84
|
| Rate for Payer: Riverside University Health MISP |
$122.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$183.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$183.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$152.85
|
| Rate for Payer: United Healthcare All Other HMO |
$152.85
|
| Rate for Payer: United Healthcare HMO Rider |
$152.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$152.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.84
|
| Rate for Payer: Vantage Medical Group Senior |
$259.84
|
|
|
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 |
$0.91 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.44
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Central Health Plan Commercial |
$3.65
|
| 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: Galaxy Health WC |
$3.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.42
|
| 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 |
1715157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.69
|
| Rate for Payer: BCBS Transplant Transplant |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California EPN |
$2.23
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Central Health Plan Commercial |
$3.65
|
| 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: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.82
|
| Rate for Payer: Galaxy Health WC |
$3.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.42
|
| Rate for Payer: IEHP medi-cal |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.42
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Prime Health Services Commercial |
$3.88
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.74
|
| Rate for Payer: Riverside University Health MISP |
$1.82
|
| 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 Medi-Cal |
$3.88
|
| Rate for Payer: Vantage Medical Group Senior |
$3.88
|
|
|
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 |
$0.88 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$70.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$66.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$49.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$45.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$49.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.93
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.93
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.58
|
| Rate for Payer: BCBS Transplant Transplant |
$49.66
|
| Rate for Payer: BCBS Transplant Transplant |
$46.80
|
| Rate for Payer: BCBS Transplant Transplant |
$54.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3.43
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$37.25
|
| Rate for Payer: Cash Price |
$37.25
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Central Health Plan Commercial |
$62.40
|
| Rate for Payer: Central Health Plan Commercial |
$66.22
|
| Rate for Payer: Central Health Plan Commercial |
$72.00
|
| Rate for Payer: Cigna of CA HMO |
$54.60
|
| Rate for Payer: Cigna of CA HMO |
$63.00
|
| Rate for Payer: Cigna of CA HMO |
$57.94
|
| Rate for Payer: Cigna of CA PPO |
$57.94
|
| Rate for Payer: Cigna of CA PPO |
$63.00
|
| Rate for Payer: Cigna of CA PPO |
$54.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$31.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.11
|
| Rate for Payer: Galaxy Health WC |
$70.35
|
| Rate for Payer: Galaxy Health WC |
$66.30
|
| Rate for Payer: Galaxy Health WC |
$76.50
|
| Rate for Payer: Global Benefits Group Commercial |
$46.80
|
| Rate for Payer: Global Benefits Group Commercial |
$49.66
|
| Rate for Payer: Global Benefits Group Commercial |
$54.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$81.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$70.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$74.49
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$62.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$58.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$67.50
|
| Rate for Payer: IEHP medi-cal |
$0.88
|
| Rate for Payer: IEHP medi-cal |
$0.88
|
| Rate for Payer: IEHP medi-cal |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.08
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: Networks By Design Commercial |
$41.38
|
| Rate for Payer: Networks By Design Commercial |
$45.00
|
| Rate for Payer: Networks By Design Commercial |
$39.00
|
| Rate for Payer: Prime Health Services Commercial |
$70.35
|
| Rate for Payer: Prime Health Services Commercial |
$76.50
|
| Rate for Payer: Prime Health Services Commercial |
$66.30
|
| Rate for Payer: Riverside University Health MISP |
$33.11
|
| Rate for Payer: Riverside University Health MISP |
$31.20
|
| Rate for Payer: Riverside University Health MISP |
$36.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$54.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$46.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$54.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$46.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO |
$41.38
|
| Rate for Payer: United Healthcare All Other HMO |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO |
$39.00
|
| Rate for Payer: United Healthcare HMO Rider |
$41.38
|
| Rate for Payer: United Healthcare HMO Rider |
$45.00
|
| Rate for Payer: United Healthcare HMO Rider |
$39.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.50
|
| Rate for Payer: Vantage Medical Group Senior |
$70.35
|
| Rate for Payer: Vantage Medical Group Senior |
$66.30
|
| Rate for Payer: Vantage Medical Group Senior |
$76.50
|
|
|
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 |
$15.60 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$58.50
|
| Rate for Payer: Blue Shield of California Commercial |
$62.08
|
| Rate for Payer: Blue Shield of California Commercial |
$67.50
|
| Rate for Payer: Blue Shield of California EPN |
$44.20
|
| Rate for Payer: Blue Shield of California EPN |
$48.06
|
| Rate for Payer: Blue Shield of California EPN |
$41.65
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$37.25
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$37.25
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Central Health Plan Commercial |
$66.22
|
| Rate for Payer: Central Health Plan Commercial |
$72.00
|
| Rate for Payer: Central Health Plan Commercial |
$62.40
|
| Rate for Payer: Cigna of CA HMO |
$63.00
|
| Rate for Payer: Cigna of CA HMO |
$54.60
|
| Rate for Payer: Cigna of CA HMO |
$57.94
|
| Rate for Payer: Cigna of CA PPO |
$57.94
|
| Rate for Payer: Cigna of CA PPO |
$54.60
|
| Rate for Payer: Cigna of CA PPO |
$63.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$31.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.00
|
| Rate for Payer: Galaxy Health WC |
$70.35
|
| Rate for Payer: Galaxy Health WC |
$76.50
|
| Rate for Payer: Galaxy Health WC |
$66.30
|
| Rate for Payer: Global Benefits Group Commercial |
$54.00
|
| Rate for Payer: Global Benefits Group Commercial |
$49.66
|
| Rate for Payer: Global Benefits Group Commercial |
$46.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$74.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$70.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$81.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.55
|
| Rate for Payer: Multiplan Commercial |
$62.08
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: Networks By Design Commercial |
$41.38
|
| Rate for Payer: Networks By Design Commercial |
$39.00
|
| Rate for Payer: Networks By Design Commercial |
$45.00
|
| Rate for Payer: Prime Health Services Commercial |
$76.50
|
| Rate for Payer: Prime Health Services Commercial |
$66.30
|
| Rate for Payer: Prime Health Services Commercial |
$70.35
|
|
