Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CEFEPIME 100 GRAM INTRAVENOUS SOLUTION [223402]

Facility

$540.00

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$297.00
Max. Negotiated Rate	$432.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$432.00
Rate for Payer: Health Smart Auto/Commercial	$324.00
Rate for Payer: LLUH Dept of Risk Management WC	$297.00
Rate for Payer: Multiplan Commercial	$405.00

CEFEPIME 100 GRAM INTRAVENOUS SOLUTION [223402]

Facility

$540.00

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$297.00
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$324.00
Rate for Payer: Aetna of CA Government/Medicare	$324.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$432.00
Rate for Payer: Health Smart Auto/Commercial	$324.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$324.00
Rate for Payer: LLUH Dept of Risk Management WC	$297.00
Rate for Payer: Multiplan Commercial	$405.00

CEFEPIME 1 GRAM IM INJECTION (PEDS) [40816369]

Facility

$6.84

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$5.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.10
Rate for Payer: Aetna of CA Government/Medicare	$4.10
Rate for Payer: Cash Price	$3.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.47
Rate for Payer: Health Smart Auto/Commercial	$4.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.10
Rate for Payer: LLUH Dept of Risk Management WC	$3.76
Rate for Payer: Multiplan Commercial	$5.13

CEFEPIME 1 GRAM IM INJECTION (PEDS) [40816369]

Facility

$6.84

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$5.47
Rate for Payer: Cash Price	$3.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.47
Rate for Payer: Health Smart Auto/Commercial	$4.10
Rate for Payer: LLUH Dept of Risk Management WC	$3.76
Rate for Payer: Multiplan Commercial	$5.13

CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]

Facility

$6.06

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$4.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.63
Rate for Payer: Aetna of CA Government/Medicare	$3.63
Rate for Payer: Aetna of CA Government/Medicare	$3.64
Rate for Payer: Cash Price	$3.33
Rate for Payer: Cash Price	$3.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.84
Rate for Payer: Health Smart Auto/Commercial	$3.64
Rate for Payer: Health Smart Auto/Commercial	$3.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.33
Rate for Payer: LLUH Dept of Risk Management WC	$3.33
Rate for Payer: Multiplan Commercial	$4.54
Rate for Payer: Multiplan Commercial	$4.54

CEFEPIME 1 GRAM SOLUTION FOR INJECTION [16369]

Facility

$6.05

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$4.84
Rate for Payer: Cash Price	$3.33
Rate for Payer: Cash Price	$3.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.84
Rate for Payer: Health Smart Auto/Commercial	$3.63
Rate for Payer: Health Smart Auto/Commercial	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.33
Rate for Payer: LLUH Dept of Risk Management WC	$3.33
Rate for Payer: Multiplan Commercial	$4.54
Rate for Payer: Multiplan Commercial	$4.54

CEFEPIME 2 GRAM SOLUTION FOR INJECTION (100 MG/ML IVPB) [16371]

Facility

$12.00

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.81
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.81
Rate for Payer: Aetna of CA Government/Medicare	$7.06
Rate for Payer: Aetna of CA Government/Medicare	$7.24
Rate for Payer: Cash Price	$6.47
Rate for Payer: Cash Price	$6.63
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$7.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.41
Rate for Payer: Health Smart Auto/Commercial	$7.81
Rate for Payer: Health Smart Auto/Commercial	$7.06
Rate for Payer: Health Smart Auto/Commercial	$7.24
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$6.63
Rate for Payer: LLUH Dept of Risk Management WC	$6.47
Rate for Payer: LLUH Dept of Risk Management WC	$7.16
Rate for Payer: Multiplan Commercial	$9.04
Rate for Payer: Multiplan Commercial	$8.82
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Commercial	$9.76

CEFEPIME 2 GRAM SOLUTION FOR INJECTION (100 MG/ML IVPB) [16371]

Facility

$11.76

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$9.41
Rate for Payer: Cash Price	$6.47
Rate for Payer: Cash Price	$6.63
Rate for Payer: Cash Price	$7.15
Rate for Payer: Cash Price	$6.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.41
Rate for Payer: Health Smart Auto/Commercial	$7.06
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$7.24
Rate for Payer: Health Smart Auto/Commercial	$7.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.47
Rate for Payer: LLUH Dept of Risk Management WC	$6.63
Rate for Payer: LLUH Dept of Risk Management WC	$7.16
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.76
Rate for Payer: Multiplan Commercial	$9.04
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Commercial	$8.82

CEFEPIME (MAXIPIME) 1G/10ML FROZEN SYRINGE [4081917]

Facility

$0.59

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41
Rate for Payer: Multiplan Commercial	$0.44

CEFEPIME (MAXIPIME) 1G/10ML FROZEN SYRINGE [4081917]

Facility

$0.59

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Commercial	$0.41

CEFEPIME (MAXIPIME) 2G/20ML FROZEN SYRINGE [4081790]

Facility

$0.54

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Commercial	$0.41

CEFEPIME (MAXIPIME) 2G/20ML FROZEN SYRINGE [4081790]

Facility

$0.54

Service Code	HCPCS J0692
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41
Rate for Payer: Multiplan Commercial	$0.44

CEFIDEROCOL 1 GRAM INTRAVENOUS SOLUTION [227170]

Facility

$279.41

Service Code	HCPCS J0699
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$153.68
Max. Negotiated Rate	$223.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$167.65
Rate for Payer: Aetna of CA Government/Medicare	$167.65
Rate for Payer: Cash Price	$153.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$223.53
Rate for Payer: Health Smart Auto/Commercial	$167.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$167.65
Rate for Payer: LLUH Dept of Risk Management WC	$153.68
Rate for Payer: Multiplan Commercial	$209.56

CEFIDEROCOL 1 GRAM INTRAVENOUS SOLUTION [227170]

Facility

$279.41

Service Code	HCPCS J0699
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$153.68
Max. Negotiated Rate	$223.53
Rate for Payer: Cash Price	$153.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$223.53
Rate for Payer: Health Smart Auto/Commercial	$167.65
Rate for Payer: LLUH Dept of Risk Management WC	$153.68
Rate for Payer: Multiplan Commercial	$209.56

CEFIDEROCOL (FETROJA) 1 GM/100 ML IVPB [40820782]

Facility

$279.41

Service Code	HCPCS J0699
Min. Negotiated Rate	$153.68
Max. Negotiated Rate	$223.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$167.65
Rate for Payer: Aetna of CA Government/Medicare	$167.65
Rate for Payer: Cash Price	$153.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$223.53
Rate for Payer: Health Smart Auto/Commercial	$167.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$167.65
Rate for Payer: LLUH Dept of Risk Management WC	$153.68
Rate for Payer: Multiplan Commercial	$209.56

CEFIDEROCOL (FETROJA) 1 GM/100 ML IVPB [40820782]

Facility

$279.41

Service Code	HCPCS J0699
Min. Negotiated Rate	$153.68
Max. Negotiated Rate	$223.53
Rate for Payer: Cash Price	$153.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$223.53
Rate for Payer: Health Smart Auto/Commercial	$167.65
Rate for Payer: LLUH Dept of Risk Management WC	$153.68
Rate for Payer: Multiplan Commercial	$209.56

CEFIXIME 200 MG/5 ML ORAL SUSPENSION [81816]

Facility

$8.02

Service Code	NDC 65862-752-75
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$6.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.81
Rate for Payer: Aetna of CA Government/Medicare	$4.81
Rate for Payer: Cash Price	$4.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.42
Rate for Payer: Health Smart Auto/Commercial	$4.81
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: Multiplan Commercial	$6.01

CEFIXIME 200 MG/5 ML ORAL SUSPENSION [81816]

Facility

$8.02

Service Code	NDC 65862-752-75
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$6.42
Rate for Payer: Cash Price	$4.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.42
Rate for Payer: Health Smart Auto/Commercial	$4.81
Rate for Payer: LLUH Dept of Risk Management WC	$4.41
Rate for Payer: Multiplan Commercial	$6.01

CEFOXITIN 10 GRAM INTRAVENOUS SOLUTION (100 MG/ML IVPB) [9462]

Facility

$107.99

Service Code	HCPCS J0694
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$59.39
Max. Negotiated Rate	$86.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.79
Rate for Payer: Aetna of CA Government/Medicare	$64.79
Rate for Payer: Cash Price	$59.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.39
Rate for Payer: Health Smart Auto/Commercial	$64.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.79
Rate for Payer: LLUH Dept of Risk Management WC	$59.39
Rate for Payer: Multiplan Commercial	$80.99

CEFOXITIN 10 GRAM INTRAVENOUS SOLUTION (100 MG/ML IVPB) [9462]

Facility

$107.99

Service Code	HCPCS J0694
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$59.39
Max. Negotiated Rate	$86.39
Rate for Payer: Cash Price	$59.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.39
Rate for Payer: Health Smart Auto/Commercial	$64.79
Rate for Payer: LLUH Dept of Risk Management WC	$59.39
Rate for Payer: Multiplan Commercial	$80.99

CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION [9461]

Facility

$11.88

Service Code	HCPCS J0694
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.53
Max. Negotiated Rate	$9.50
Rate for Payer: Cash Price	$6.53
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$5.03
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Health Smart Auto/Commercial	$7.13
Rate for Payer: LLUH Dept of Risk Management WC	$6.53
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$4.61
Rate for Payer: Multiplan Commercial	$8.91
Rate for Payer: Multiplan Commercial	$6.29
Rate for Payer: Multiplan Commercial	$5.40

CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION [9461]

Facility

$11.88

Service Code	HCPCS J0694
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.53
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.03
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$7.13
Rate for Payer: Aetna of CA Government/Medicare	$5.03
Rate for Payer: Cash Price	$6.53
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.71
Rate for Payer: Health Smart Auto/Commercial	$5.03
Rate for Payer: Health Smart Auto/Commercial	$7.13
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.03
Rate for Payer: LLUH Dept of Risk Management WC	$6.53
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$4.61
Rate for Payer: Multiplan Commercial	$6.29
Rate for Payer: Multiplan Commercial	$5.40
Rate for Payer: Multiplan Commercial	$8.91

CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [9463]

Facility

$9.60

Service Code	HCPCS J0694
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.05
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$5.76
Rate for Payer: Aetna of CA Government/Medicare	$10.05
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$5.28
Rate for Payer: Cash Price	$9.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.40
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$10.05
Rate for Payer: Health Smart Auto/Commercial	$5.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.76
Rate for Payer: LLUH Dept of Risk Management WC	$9.21
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$5.28
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Commercial	$12.56
Rate for Payer: Multiplan Commercial	$7.20

CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [9463]

Facility

$9.60

Service Code	HCPCS J0694
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$7.68
Rate for Payer: Cash Price	$5.28
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$9.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$10.05
Rate for Payer: Health Smart Auto/Commercial	$5.76
Rate for Payer: LLUH Dept of Risk Management WC	$5.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$9.21
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Commercial	$12.56
Rate for Payer: Multiplan Commercial	$7.20

CEFPODOXIME 200 MG TABLET [9469]

Facility

$4.48

Service Code	NDC 65862-096-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$3.58
Rate for Payer: Cash Price	$2.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.58
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.46
Rate for Payer: Multiplan Commercial	$3.36

Know your out-of-pocket cost for care.

All Charges