|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
OP
|
$89.76
|
|
|
Service Code
|
CPT J2247
|
| Hospital Charge Code |
1759996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$67.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$53.86
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$67.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$67.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$53.86
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$53.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$67.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$67.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$53.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$84.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$67.32
|
|
|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
IP
|
$89.76
|
|
|
Service Code
|
CPT J2247
|
| Hospital Charge Code |
1759996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$71.81 |
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$89.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$67.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$53.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.71
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$67.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$84.15
|
|
|
MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY [10603]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 61269-736-07
|
| Hospital Charge Code |
1743521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.05
|
|
|
MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY [10603]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 61269-736-07
|
| Hospital Charge Code |
1743521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.05 |
| 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 |
$0.63
|
| 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 Beech St/Commercial/PHCS |
$1.05
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
IP
|
$9.23
|
|
|
Service Code
|
NDC 0904-5415-01
|
| Hospital Charge Code |
ERX24855
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Cash Price |
$4.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.92
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
OP
|
$9.23
|
|
|
Service Code
|
NDC 0904-5415-01
|
| Hospital Charge Code |
ERX24855
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.54
|
| Rate for Payer: Cash Price |
$4.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.92
|
|
|
MICONAZOLE NITRATE 200 MG/5 GRAM (4 %) VAGINAL CREAM [110914]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 3551596614
|
| Hospital Charge Code |
1743726
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
MICONAZOLE NITRATE 200 MG/5 GRAM (4 %) VAGINAL CREAM [110914]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 3551596614
|
| Hospital Charge Code |
1743726
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
MICONAZOLE NITRATE 200 MG/5 GRAM (4 %) VAGINAL CREAM [110914]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 6373644201
|
| Hospital Charge Code |
NDG110914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.69
|
|
|
MICONAZOLE NITRATE 200 MG/5 GRAM (4 %) VAGINAL CREAM [110914]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 6373644201
|
| Hospital Charge Code |
NDG110914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.69
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 0472-1738-03
|
| Hospital Charge Code |
1743519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Cash Price |
$8.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.32
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
NDC 0472-1738-03
|
| Hospital Charge Code |
1743519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$14.32 |
| 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 |
$8.60
|
| 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 |
$10.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$14.32
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0536-1134-28
|
| Hospital Charge Code |
NDG5039C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 11701-045-23
|
| Hospital Charge Code |
NDG5039C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0536-1134-28
|
| Hospital Charge Code |
NDG5039C
|
|
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 |
$0.08
|
| 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 11701-045-23
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 11701-045-23
|
| Hospital Charge Code |
NDG5039C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 11701-045-23
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0316-0225-30
|
| Hospital Charge Code |
1743650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0316-0225-30
|
| Hospital Charge Code |
1743650
|
|
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: 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 Beech St/Commercial/PHCS |
$0.06
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7734-45
|
| Hospital Charge Code |
1743423
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7734-45
|
| Hospital Charge Code |
1743423
|
|
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 |
$0.06
|
| 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 24385-590-29
|
| Hospital Charge Code |
1743423
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.09
|
| 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 Beech St/Commercial/PHCS |
$0.15
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
1743423
|
|
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 |
$0.09
|
| 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 51672-2035-6
|
| Hospital Charge Code |
1743423
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| 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 |
$0.10
|
| 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 Beech St/Commercial/PHCS |
$0.17
|
|
