|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 6068779211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 6068779201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 6068779201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
NDC 0781183120
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Senior |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Vantage Medical Group Senior |
$0.97
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 0781183120
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
AMOXICILLIN 500 MG TABLET [17456]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 6586201401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
AMOXICILLIN 500 MG TABLET [17456]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 6586201401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 0781185201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Senior |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 4257116242
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
NDC 0781185220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| 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 |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| 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 |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 0781185220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Senior |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6586250301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| 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 |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| 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 |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.72
|
|
|
Service Code
|
NDC 4257116201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 6586250320
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| 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 |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| 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 |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 6586250301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 4257116242
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| 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 |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| 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 |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$1.36
|
|
|
Service Code
|
NDC 0781185201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| 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 |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| 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 |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 4257116201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| 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 |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| 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 |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 6586250320
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 0781194382
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.00
|
| 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 |
$4.05
|
| Rate for Payer: Blue Shield of California Commercial |
$4.93
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.26
|
| 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 |
$5.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 0781194339
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.00
|
| 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 |
$4.05
|
| Rate for Payer: Blue Shield of California Commercial |
$4.93
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.26
|
| 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 |
$5.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$6.70
|
|
|
Service Code
|
NDC 4359822028
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.03 |
| Rate for Payer: Adventist Health Commercial |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.31
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.54
|
| Rate for Payer: Heritage Provider Network Senior |
$4.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.03
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
OP
|
$6.70
|
|
|
Service Code
|
NDC 4359822028
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Adventist Health Commercial |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| 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 |
$3.35
|
| Rate for Payer: Blue Shield of California Commercial |
$4.09
|
| Rate for Payer: Blue Shield of California EPN |
$3.27
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.36
|
| 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 |
$4.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.15
|
| Rate for Payer: Heritage Provider Network Senior |
$4.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.69
|
| Rate for Payer: Multiplan Commercial |
$5.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.68
|
| Rate for Payer: TriValley Medical Group Senior |
$2.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 0781194339
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
|
|
AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 0781194382
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
|
