|
MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY [10603]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 61269-736-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY [10603]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 61269-736-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
OP
|
$11.75
|
|
|
Service Code
|
NDC 24385-606-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.05
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.46
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
IP
|
$11.75
|
|
|
Service Code
|
NDC 24385-606-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.46
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
NDC 0472-1738-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.46
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.51
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 0472-1738-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.51
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 68001-481-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 61269-735-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 68001-481-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0536-1375-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 61269-735-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0536-1375-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0316-0225-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| 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 |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0316-0225-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 51672-2035-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 51672-2035-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7734-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7734-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 24385-590-29
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 24385-590-29
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT 8 CM X 6.25 CM X 1 CM SPONGE [33186]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 53276-1050-03
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$39.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$39.60
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$52.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$39.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.30
|
| Rate for Payer: Multiplan Commercial |
$49.50
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT 8 CM X 6.25 CM X 1 CM SPONGE [33186]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 53276-1050-03
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$52.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$39.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.30
|
| Rate for Payer: Multiplan Commercial |
$49.50
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP [121529]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 68094-764-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
|
