|
VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]
|
Facility
|
OP
|
$8.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.04
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
|
|
VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]
|
Facility
|
IP
|
$6.51
|
|
|
Service Code
|
NDC 0409-6534-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$4.88
|
|
|
VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]
|
Facility
|
OP
|
$6.51
|
|
|
Service Code
|
NDC 0409-6534-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.91
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$4.88
|
|
|
VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$7.83 |
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$7.83 |
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Multiplan Commercial |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]
|
Facility
|
OP
|
$3.54
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.04
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Multiplan Commercial |
$2.65
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION (NO TROUGH GOAL) [4081893]
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
HCPCS J3374
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Cash Price |
$5.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.31
|
| Rate for Payer: Multiplan Commercial |
$7.24
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION (NO TROUGH GOAL) [4081893]
|
Facility
|
OP
|
$8.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.04
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.04
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION (NO TROUGH GOAL) [4081893]
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
HCPCS J3374
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.79
|
| Rate for Payer: Cash Price |
$5.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.31
|
| Rate for Payer: Multiplan Commercial |
$7.24
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION (NO TROUGH GOAL) [4081893]
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$7.83 |
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.38
|
| Rate for Payer: Multiplan Commercial |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
|
|
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION [8444]
|
Facility
|
OP
|
$95.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.47 |
| Max. Negotiated Rate |
$76.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.24
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.54
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$35.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$35.99
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Cash Price |
$52.47
|
| Rate for Payer: Cash Price |
$32.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$76.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$35.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.47
|
| Rate for Payer: Multiplan Commercial |
$21.93
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
|
|
VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION [8444]
|
Facility
|
IP
|
$95.40
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.47 |
| Max. Negotiated Rate |
$76.32 |
| Rate for Payer: Cash Price |
$52.47
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Cash Price |
$32.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$47.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$76.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$35.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.99
|
| Rate for Payer: Multiplan Commercial |
$21.93
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
|
|
VANCOMYCIN 5 MG/ML SERIAL DILUTION FOR MIXTURES [4080888]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
VANCOMYCIN 5 MG/ML SERIAL DILUTION FOR MIXTURES [4080888]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
VANCOMYCIN 750 MG/150 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [108740]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
VANCOMYCIN 750 MG/150 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [108740]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]
|
Facility
|
OP
|
$11.80
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.08
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$6.49
|
| Rate for Payer: Cash Price |
$4.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.49
|
| Rate for Payer: Multiplan Commercial |
$8.85
|
| Rate for Payer: Multiplan Commercial |
$6.01
|
|
|
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]
|
Facility
|
IP
|
$11.80
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Cash Price |
$6.49
|
| Rate for Payer: Cash Price |
$4.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.49
|
| Rate for Payer: Multiplan Commercial |
$8.85
|
| Rate for Payer: Multiplan Commercial |
$6.01
|
|
|
VANCOMYCIN/BSS 2MG/0.2ML SYRINGE [4081576]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
NDC 9994-0815-76
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
VANCOMYCIN/BSS 2MG/0.2ML SYRINGE [4081576]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
NDC 9994-0815-76
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
VANCOMYCIN (BULK) 900 MCG/MG (NOT LESS THAN) POWDER [12217]
|
Facility
|
OP
|
$232.56
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$186.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$139.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$139.54
|
| Rate for Payer: Cash Price |
$127.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$186.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$139.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$139.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.91
|
| Rate for Payer: Multiplan Commercial |
$174.42
|
|
|
VANCOMYCIN (BULK) 900 MCG/MG (NOT LESS THAN) POWDER [12217]
|
Facility
|
IP
|
$232.56
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$186.05 |
| Rate for Payer: Cash Price |
$127.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$186.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$139.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.91
|
| Rate for Payer: Multiplan Commercial |
$174.42
|
|
|
VANCOMYCIN ORAL SOLUTION (IV FORM) 50 MG/ML [4080446]
|
Facility
|
IP
|
$1.03
|
|
|
Service Code
|
NDC 9994-0804-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
VANCOMYCIN ORAL SOLUTION (IV FORM) 50 MG/ML [4080446]
|
Facility
|
OP
|
$1.03
|
|
|
Service Code
|
NDC 9994-0804-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [14757]
|
Facility
|
IP
|
$218.70
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.28 |
| Max. Negotiated Rate |
$174.96 |
| Rate for Payer: Cash Price |
$120.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$174.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$131.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.28
|
| Rate for Payer: Multiplan Commercial |
$164.03
|
|
