|
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION [208439]
|
Facility
|
IP
|
$209.23
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$167.38 |
| Rate for Payer: Cash Price |
$115.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$167.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$125.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.08
|
| Rate for Payer: Multiplan Commercial |
$156.92
|
|
|
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION [208439]
|
Facility
|
OP
|
$209.23
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$167.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$125.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$125.54
|
| Rate for Payer: Cash Price |
$115.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$167.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$125.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$125.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.08
|
| Rate for Payer: Multiplan Commercial |
$156.92
|
|
|
CEFTRIAXONE 10 GRAM SOLUTION FOR INJECTION [9491]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$32.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.08
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$15.59
|
| Rate for Payer: Multiplan Commercial |
$30.11
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
|
|
CEFTRIAXONE 10 GRAM SOLUTION FOR INJECTION [9491]
|
Facility
|
OP
|
$20.78
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$16.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.47
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$20.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$20.16
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$19.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$32.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$20.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$30.11
|
| Rate for Payer: Multiplan Commercial |
$15.59
|
|
|
CEFTRIAXONE 1 GRAM INJECTION (IM) [4080782]
|
Facility
|
OP
|
$1.83
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.10
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
|
|
CEFTRIAXONE 1 GRAM INJECTION (IM) [4080782]
|
Facility
|
IP
|
$1.83
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
|
|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION (1000 MG/10 ML IVPB) [9487]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
|
|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION (1000 MG/10 ML IVPB) [9487]
|
Facility
|
IP
|
$1.83
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
CEFTRIAXONE 250 MG INJECTION (IM) [4080777]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
CEFTRIAXONE 250 MG INJECTION (IM) [4080777]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [9489]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.01
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.22
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
|
|
CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [9489]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.73
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
|
|
CEFTRIAXONE 2 GRAM INJECTION (IM) [4080783]
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
|
|
CEFTRIAXONE 2 GRAM INJECTION (IM) [4080783]
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
|
|
CEFTRIAXONE 2 GRAM INTRAVENOUS SOLUTION [27309]
|
Facility
|
OP
|
$9.57
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$7.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.74
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: Multiplan Commercial |
$7.18
|
|
|
CEFTRIAXONE 2 GRAM INTRAVENOUS SOLUTION [27309]
|
Facility
|
IP
|
$9.57
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$7.66 |
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.26
|
| Rate for Payer: Multiplan Commercial |
$7.18
|
|
|
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cash Price |
$5.15
|
| Rate for Payer: Cash Price |
$4.42
|
| 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 |
$2.78
|
| 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 |
$6.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$6.02
|
| Rate for Payer: Multiplan Commercial |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
|
|
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.08
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.62
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.82
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.62
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$5.15
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Cash Price |
$3.96
|
| 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 |
$7.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.78
|
| 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 |
$6.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$6.02
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
|
|
CEFTRIAXONE 500 MG INJECTION (IM) [4080778]
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
|
|
CEFTRIAXONE 500 MG INJECTION (IM) [4080778]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
|
|
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [9490]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.62
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.62
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
|
|
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [9490]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
CEFTRIAXONE/H2O IV INFUSION 100 MG/ML [4081845]
|
Facility
|
IP
|
$19.06
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$15.25 |
| Rate for Payer: Cash Price |
$10.48
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$32.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.43
|
| Rate for Payer: Multiplan Commercial |
$30.11
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$15.59
|
| Rate for Payer: Multiplan Commercial |
$14.29
|
|
|
CEFTRIAXONE/H2O IV INFUSION 100 MG/ML [4081845]
|
Facility
|
OP
|
$20.78
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$16.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.47
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.44
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$20.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$20.16
|
| Rate for Payer: Cash Price |
$10.48
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$26.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$32.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$20.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$20.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.08
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$15.59
|
| Rate for Payer: Multiplan Commercial |
$30.11
|
|
|
CEFTRIAXONE (ROCEPHIN) 1G/10 ML FROZEN SYRINGE [4081848]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
