|
CEFTAROLINE FOSAMIL (TEFLARO) 400MG IVPB
|
Facility
|
OP
|
$943.00
|
|
|
Service Code
|
NDC 456040010
|
| Hospital Charge Code |
2624127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$339.48 |
| Max. Negotiated Rate |
$673.30 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$558.26
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$673.30
|
| Rate for Payer: Cash Price |
$848.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$628.98
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$339.48
|
|
|
CEFTAROLINE FOSAMIL (TEFLARO) 600MG IVPB
|
Facility
|
OP
|
$943.00
|
|
|
Service Code
|
NDC 456060010
|
| Hospital Charge Code |
2620043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$339.48 |
| Max. Negotiated Rate |
$673.30 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$558.26
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$673.30
|
| Rate for Payer: Cash Price |
$848.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$628.98
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$339.48
|
|
|
CEFTAROLINE FOSAMIL (TEFLARO) 600MG IVPB
|
Facility
|
IP
|
$943.00
|
|
|
Service Code
|
NDC 456060010
|
| Hospital Charge Code |
2620043
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$848.70
|
|
|
CEFTAZIDIME 2GM IVPB VIAL
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2627086
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$83.70
|
|
|
CEFTAZIDIME 2GM IVPB VIAL
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2627086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.48 |
| Max. Negotiated Rate |
$66.40 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$55.06
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$66.40
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$62.03
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$33.48
|
|
|
CEFTAZIDIME (FORTAZ) 500MG INJ
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2654418
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$44.10
|
|
|
CEFTAZIDIME (FORTAZ) 500MG INJ
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2654418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$34.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$29.01
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$34.99
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$17.64
|
|
|
CEFTAZIDIME (FORTAZ) 500MG IVPB
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2619994
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$44.98 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$37.30
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$44.98
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$22.68
|
|
|
CEFTAZIDIME (FORTAZ) 500MG IVPB
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2619994
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$56.70
|
|
|
CEFTAZIDIME + NS : 2GM + NS MB 100ML
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2626592
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$298.80
|
|
|
CEFTAZIDIME + NS : 2GM + NS MB 100ML
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
2626592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.52 |
| Max. Negotiated Rate |
$237.05 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$196.54
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$237.05
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$221.44
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$119.52
|
|
|
CEFTIZDXIME IVPB
|
Facility
|
IP
|
$594.00
|
|
| Hospital Charge Code |
2058092
|
|
Hospital Revenue Code
|
370
|
| Rate for Payer: Cash Price |
$534.60
|
|
|
CEFTIZDXIME IVPB
|
Facility
|
OP
|
$594.00
|
|
| Hospital Charge Code |
2058092
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$213.84 |
| Max. Negotiated Rate |
$424.12 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$351.65
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$424.12
|
| Rate for Payer: Cash Price |
$534.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$396.20
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$213.84
|
|
|
CEFTRIAXONE 250MG IM (J0696)
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
4290789
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
CEFTRIAXONE 250MG IM (J0696)
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
4290789
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
CEFTRIAXONE + LIDO : 1GM + 2ML IM INJ
|
Facility
|
OP
|
$521.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2627112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.56 |
| Max. Negotiated Rate |
$371.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$308.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$371.99
|
| Rate for Payer: Cash Price |
$468.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$347.51
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$187.56
|
|
|
CEFTRIAXONE + LIDO : 1GM + 2ML IM INJ
|
Facility
|
IP
|
$521.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2627112
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$468.90
|
|
|
CEFTRIAXONE + NS : 1GM + 100ML MINIBAG
|
Facility
|
OP
|
$1,236.00
|
|
|
Service Code
|
NDC 1E+11
|
| Hospital Charge Code |
2623495
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$444.96 |
| Max. Negotiated Rate |
$882.50 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$731.71
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$882.50
|
| Rate for Payer: Cash Price |
$1,112.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$824.41
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$444.96
|
|
|
CEFTRIAXONE + NS : 1GM + 100ML MINIBAG
|
Facility
|
IP
|
$1,236.00
|
|
|
Service Code
|
NDC 1E+11
|
| Hospital Charge Code |
2623495
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$1,112.40
|
|
|
CEFTRIAXONE + NS : 2GM + 100ML MINIBAG
|
Facility
|
IP
|
$1,236.00
|
|
|
Service Code
|
NDC 1E+11
|
| Hospital Charge Code |
2623852
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$1,112.40
|
|
|
CEFTRIAXONE + NS : 2GM + 100ML MINIBAG
|
Facility
|
OP
|
$1,236.00
|
|
|
Service Code
|
NDC 1E+11
|
| Hospital Charge Code |
2623852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$444.96 |
| Max. Negotiated Rate |
$882.50 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$731.71
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$882.50
|
| Rate for Payer: Cash Price |
$1,112.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$824.41
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$444.96
|
|
|
CEFTRIAXONE (ROCEPHIN) 1GM VIAL
|
Facility
|
IP
|
$521.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2656157
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$468.90
|
|
|
CEFTRIAXONE (ROCEPHIN) 1GM VIAL
|
Facility
|
OP
|
$521.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2656157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.56 |
| Max. Negotiated Rate |
$371.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$308.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$371.99
|
| Rate for Payer: Cash Price |
$468.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$347.51
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$187.56
|
|
|
CEFTRIAXONE (ROCEPHIN) 250MG VIAL
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2697048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$199.92 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$165.76
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$199.92
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$186.76
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$100.80
|
|
|
CEFTRIAXONE (ROCEPHIN) 250MG VIAL
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2697048
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$252.00
|
|
