|
CEFPODOXIME 200 MG TABLET [9469]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$2.69
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.69
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
|
|
CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION [107670]
|
Facility
|
IP
|
$308.95
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.92 |
| Max. Negotiated Rate |
$247.16 |
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$247.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$185.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.92
|
| Rate for Payer: Multiplan Commercial |
$231.71
|
|
|
CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION [107670]
|
Facility
|
OP
|
$308.95
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.92 |
| Max. Negotiated Rate |
$247.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$185.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$185.37
|
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$247.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$185.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$185.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.92
|
| Rate for Payer: Multiplan Commercial |
$231.71
|
|
|
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION [107671]
|
Facility
|
OP
|
$308.95
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.92 |
| Max. Negotiated Rate |
$247.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$185.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$185.37
|
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$247.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$185.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$185.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.92
|
| Rate for Payer: Multiplan Commercial |
$231.71
|
|
|
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION [107671]
|
Facility
|
IP
|
$308.95
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.92 |
| Max. Negotiated Rate |
$247.16 |
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$247.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$185.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.92
|
| Rate for Payer: Multiplan Commercial |
$231.71
|
|
|
CEFTAZIDIME 10 MG/ML SERIAL DILUTION FOR MIXTURES [4080886]
|
Facility
|
IP
|
$5.12
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
|
|
CEFTAZIDIME 10 MG/ML SERIAL DILUTION FOR MIXTURES [4080886]
|
Facility
|
OP
|
$5.12
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.07
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
|
|
CEFTAZIDIME 1 GRAM INTRAVENOUS SOLUTION [27290]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.28
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
CEFTAZIDIME 1 GRAM INTRAVENOUS SOLUTION [27290]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION (200 MG/ML RECONST) [4081895]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$2.93
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION (200 MG/ML RECONST) [4081895]
|
Facility
|
OP
|
$3.91
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.35
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.74
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.24
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.35
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$2.93
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]
|
Facility
|
IP
|
$3.91
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$2.93
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]
|
Facility
|
OP
|
$5.12
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.07
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.35
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.24
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.24
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$2.93
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$4.68
|
|
|
CEFTAZIDIME 2 GRAM INTRAVENOUS SOLUTION [111787]
|
Facility
|
IP
|
$14.51
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$11.61 |
| Rate for Payer: Cash Price |
$7.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$10.88
|
|
|
CEFTAZIDIME 2 GRAM INTRAVENOUS SOLUTION [111787]
|
Facility
|
OP
|
$14.51
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$11.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.71
|
| Rate for Payer: Cash Price |
$7.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$11.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.98
|
| Rate for Payer: Multiplan Commercial |
$10.88
|
|
|
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [9476]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.88
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$8.60
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [9476]
|
Facility
|
IP
|
$11.46
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$8.60
|
|
|
CEFTAZIDIME 6 GRAM SOLUTION FOR INJECTION (100MG/ML IVPB) [9478]
|
Facility
|
IP
|
$26.03
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$20.82 |
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cash Price |
$19.25
|
| Rate for Payer: Cash Price |
$20.17
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$29.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.84
|
| Rate for Payer: Multiplan Commercial |
$27.51
|
| Rate for Payer: Multiplan Commercial |
$26.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$19.52
|
|
|
CEFTAZIDIME 6 GRAM SOLUTION FOR INJECTION (100MG/ML IVPB) [9478]
|
Facility
|
OP
|
$28.80
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$23.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$17.28
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$22.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$17.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$22.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.00
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cash Price |
$19.25
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Cash Price |
$20.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$20.82
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$23.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$29.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$22.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$17.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$17.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$22.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.17
|
| Rate for Payer: Multiplan Commercial |
$26.25
|
| Rate for Payer: Multiplan Commercial |
$19.52
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$27.51
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [205130]
|
Facility
|
IP
|
$498.44
|
|
|
Service Code
|
HCPCS J0714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.14 |
| Max. Negotiated Rate |
$398.75 |
| Rate for Payer: Cash Price |
$274.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$398.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$299.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.14
|
| Rate for Payer: Multiplan Commercial |
$373.83
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [205130]
|
Facility
|
OP
|
$498.44
|
|
|
Service Code
|
HCPCS J0714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.14 |
| Max. Negotiated Rate |
$398.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$299.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$299.06
|
| Rate for Payer: Cash Price |
$274.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$398.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$299.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$299.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$274.14
|
| Rate for Payer: Multiplan Commercial |
$373.83
|
|
|
CEFTAZIDIME (FORTAZ) 1G/10ML FROZEN SYRINGE [4081276]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
CEFTAZIDIME (FORTAZ) 1G/10ML FROZEN SYRINGE [4081276]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| 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: Multiplan Commercial |
$0.44
|
|
|
CEFTAZIDIME (FORTAZ) 2G/20ML FROZEN SYRINGE [4081279]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| 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: Multiplan Commercial |
$0.44
|
|
|
CEFTAZIDIME (FORTAZ) 2G/20ML FROZEN SYRINGE [4081279]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
