|
CEFTRIAXONE (ROCEPHIN) 1G/10 ML FROZEN SYRINGE [4081848]
|
Facility
|
OP
|
$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: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
CEFTRIAXONE (ROCEPHIN) 2G/20 ML FROZEN SYRINGE [4081846]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J0696
|
| 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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
|
|
CEFTRIAXONE (ROCEPHIN) 2G/20 ML FROZEN SYRINGE [4081846]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$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: Cash Price |
$2.97
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
|
|
CEFUROXIME AXETIL 250 MG TABLET [9495]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 67877-215-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
CEFUROXIME AXETIL 250 MG TABLET [9495]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 67877-215-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION [111827]
|
Facility
|
OP
|
$6.51
|
|
|
Service Code
|
HCPCS J0697
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 EPO/HMO/POS/PPO |
$4.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.21
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$4.88
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION [111827]
|
Facility
|
IP
|
$6.51
|
|
|
Service Code
|
HCPCS J0697
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$4.88
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION [1465]
|
Facility
|
OP
|
$3.51
|
|
|
Service Code
|
HCPCS J0697
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.11
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
|
|
CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION [1465]
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
HCPCS J0697
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$2.63
|
|
|
CEFUROXIME (ZINACEF) 1.5G/15ML FROZEN SYRINGE [4081783]
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
HCPCS J0697
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.82
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.82
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
CEFUROXIME (ZINACEF) 1.5G/15ML FROZEN SYRINGE [4081783]
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
HCPCS J0697
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 50268-168-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 33342-156-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 62332-141-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 0904-6502-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 60687-436-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 50268-168-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 60687-436-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 62332-141-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 50268-168-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 0904-6502-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.87
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 50268-168-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
CELECOXIB 100 MG CAPSULE [24500]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 33342-156-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
CELECOXIB 200 MG CAPSULE [24501]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 51079-215-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
|
|
CELECOXIB 200 MG CAPSULE [24501]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 51079-215-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.32
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
|
