|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 0527-4107-37
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 50742-239-01
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
MEXILETINE 150 MG CAPSULE [10595]
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
NDC 0093-8739-01
|
| Hospital Charge Code |
1712090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.08
|
| Rate for Payer: Cigna of CA PPO |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.32
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0093-8740-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: Blue Distinction Transplant |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.10
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Media |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO |
$0.95
|
| Rate for Payer: United Healthcare HMO Rider |
$0.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 62756-956-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.99
|
| Rate for Payer: Cigna of CA PPO |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.92
|
| Rate for Payer: Prime Health Services Commercial |
$1.21
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0093-8740-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 50742-240-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 62756-956-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Distinction Transplant |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.99
|
| Rate for Payer: Cigna of CA PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.21
|
| Rate for Payer: Dignity Health Media |
$1.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.92
|
| Rate for Payer: Prime Health Services Commercial |
$1.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.71
|
| Rate for Payer: United Healthcare All Other HMO |
$0.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.21
|
| Rate for Payer: Vantage Medical Group Senior |
$1.21
|
|
|
MEXILETINE 200 MG CAPSULE [10596]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 50742-240-01
|
| Hospital Charge Code |
1712595
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Distinction Transplant |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Media |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0816-49
|
| Hospital Charge Code |
NDC4081649
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0816-49
|
| Hospital Charge Code |
NDC4081649
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
OP
|
$112.20
|
|
|
Service Code
|
CPT J2247
|
| Hospital Charge Code |
1759996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.18
|
| Rate for Payer: Blue Distinction Transplant |
$53.86
|
| Rate for Payer: Blue Distinction Transplant |
$67.32
|
| Rate for Payer: Blue Shield of California Commercial |
$66.15
|
| Rate for Payer: Blue Shield of California Commercial |
$82.69
|
| Rate for Payer: Blue Shield of California EPN |
$65.52
|
| Rate for Payer: Blue Shield of California EPN |
$52.42
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Cigna of CA HMO |
$78.54
|
| Rate for Payer: Cigna of CA HMO |
$62.83
|
| Rate for Payer: Cigna of CA PPO |
$62.83
|
| Rate for Payer: Cigna of CA PPO |
$78.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$95.37
|
| Rate for Payer: Galaxy Health WC |
$76.30
|
| Rate for Payer: Global Benefits Group Commercial |
$53.86
|
| Rate for Payer: Global Benefits Group Commercial |
$67.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$67.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$84.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.55
|
| Rate for Payer: Heritage Provider Network Transplant |
$0.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$0.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$0.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$59.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$74.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$89.76
|
| Rate for Payer: Multiplan Commercial |
$71.81
|
| Rate for Payer: Networks By Design Commercial |
$44.88
|
| Rate for Payer: Networks By Design Commercial |
$56.10
|
| Rate for Payer: Prime Health Services Commercial |
$76.30
|
| Rate for Payer: Prime Health Services Commercial |
$95.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$67.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$53.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$67.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$53.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.10
|
| Rate for Payer: United Healthcare All Other HMO |
$56.10
|
| Rate for Payer: United Healthcare All Other HMO |
$44.88
|
| Rate for Payer: United Healthcare HMO Rider |
$56.10
|
| Rate for Payer: United Healthcare HMO Rider |
$44.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$44.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$56.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
IP
|
$112.20
|
|
|
Service Code
|
CPT J2247
|
| Hospital Charge Code |
1759996
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.93 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: Blue Shield of California Commercial |
$79.89
|
| Rate for Payer: Blue Shield of California Commercial |
$63.91
|
| Rate for Payer: Blue Shield of California EPN |
$57.45
|
| Rate for Payer: Blue Shield of California EPN |
$45.96
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cigna of CA HMO |
$78.54
|
| Rate for Payer: Cigna of CA HMO |
$62.83
|
| Rate for Payer: Cigna of CA PPO |
$62.83
|
| Rate for Payer: Cigna of CA PPO |
$78.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$35.90
|
| Rate for Payer: Galaxy Health WC |
$95.37
|
| Rate for Payer: Galaxy Health WC |
$76.30
|
| Rate for Payer: Global Benefits Group Commercial |
$53.86
|
| Rate for Payer: Global Benefits Group Commercial |
$67.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$59.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$74.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.54
|
| Rate for Payer: Multiplan Commercial |
$89.76
|
| Rate for Payer: Multiplan Commercial |
$71.81
|
| Rate for Payer: Networks By Design Commercial |
$56.10
|
| Rate for Payer: Networks By Design Commercial |
$44.88
|
| Rate for Payer: Prime Health Services Commercial |
$95.37
|
| Rate for Payer: Prime Health Services Commercial |
$76.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.89
|
| Rate for Payer: United Healthcare All Other HMO |
$41.38
|
| Rate for Payer: United Healthcare All Other HMO |
$33.10
|
| Rate for Payer: United Healthcare HMO Rider |
$40.48
|
| Rate for Payer: United Healthcare HMO Rider |
$32.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.62
|
|
|
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 |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Distinction Transplant |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Media |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
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 |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
|
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 |
$2.22 |
| Max. Negotiated Rate |
$7.85 |
| Rate for Payer: Blue Shield of California Commercial |
$6.57
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$4.15
|
| Rate for Payer: Cigna of CA HMO |
$6.46
|
| Rate for Payer: Cigna of CA PPO |
$6.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.69
|
| Rate for Payer: Galaxy Health WC |
$7.85
|
| Rate for Payer: Global Benefits Group Commercial |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$7.38
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$7.85
|
|
|
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 |
$2.22 |
| Max. Negotiated Rate |
$7.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.50
|
| Rate for Payer: Blue Distinction Transplant |
$5.54
|
| Rate for Payer: Blue Shield of California Commercial |
$6.80
|
| Rate for Payer: Blue Shield of California EPN |
$5.39
|
| Rate for Payer: Cash Price |
$4.15
|
| Rate for Payer: Cigna of CA HMO |
$6.46
|
| Rate for Payer: Cigna of CA PPO |
$6.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.85
|
| Rate for Payer: Dignity Health Media |
$7.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.69
|
| Rate for Payer: Galaxy Health WC |
$7.85
|
| Rate for Payer: Global Benefits Group Commercial |
$5.54
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$7.38
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$7.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.62
|
| Rate for Payer: United Healthcare All Other HMO |
$4.62
|
| Rate for Payer: United Healthcare HMO Rider |
$4.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.85
|
| Rate for Payer: Vantage Medical Group Senior |
$7.85
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Distinction Transplant |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Media |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
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 |
$4.58 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.38
|
| Rate for Payer: Blue Distinction Transplant |
$11.46
|
| Rate for Payer: Blue Shield of California Commercial |
$14.08
|
| Rate for Payer: Blue Shield of California EPN |
$11.15
|
| Rate for Payer: Cash Price |
$8.60
|
| Rate for Payer: Cigna of CA HMO |
$13.37
|
| Rate for Payer: Cigna of CA PPO |
$13.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.24
|
| Rate for Payer: Dignity Health Media |
$16.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.64
|
| Rate for Payer: Galaxy Health WC |
$16.24
|
| Rate for Payer: Global Benefits Group Commercial |
$11.46
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$15.28
|
| Rate for Payer: Networks By Design Commercial |
$12.42
|
| Rate for Payer: Prime Health Services Commercial |
$16.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.55
|
| Rate for Payer: United Healthcare All Other HMO |
$9.55
|
| Rate for Payer: United Healthcare HMO Rider |
$9.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.24
|
| Rate for Payer: Vantage Medical Group Senior |
$16.24
|
|
|
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 |
$4.58 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Blue Shield of California Commercial |
$13.60
|
| Rate for Payer: Blue Shield of California EPN |
$9.78
|
| Rate for Payer: Cash Price |
$8.60
|
| Rate for Payer: Cigna of CA HMO |
$13.37
|
| Rate for Payer: Cigna of CA PPO |
$13.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.64
|
| Rate for Payer: Galaxy Health WC |
$16.24
|
| Rate for Payer: Global Benefits Group Commercial |
$11.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.58
|
| Rate for Payer: Multiplan Commercial |
$15.28
|
| Rate for Payer: Networks By Design Commercial |
$12.42
|
| Rate for Payer: Prime Health Services Commercial |
$16.24
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
|
