|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6800148147
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| 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 |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| 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: Riverside University Health System MISP |
$0.04
|
| 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
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6126973556
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| 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 |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| 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: Riverside University Health System MISP |
$0.04
|
| 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
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6800148147
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| 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
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0536137575
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0536137575
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| 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 POWDER [10599]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0316022530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0316022530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0904773445
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 2438559029
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0904773445
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 5167220356
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Riverside University Health System MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 5167220356
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 2438559029
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT 8 CM X 6.25 CM X 1 CM SPONGE [33186]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 53276105003
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Adventist Health Commercial |
$13.20
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Central Health Plan Commercial |
$52.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$46.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.40
|
| Rate for Payer: EPIC Health Plan Senior |
$26.40
|
| Rate for Payer: Galaxy Health WC |
$56.10
|
| Rate for Payer: Global Benefits Group Commercial |
$39.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$59.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$41.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$38.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Multiplan Commercial |
$49.50
|
| Rate for Payer: Networks By Design Commercial |
$42.90
|
| Rate for Payer: Prime Health Services Commercial |
$56.10
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT 8 CM X 6.25 CM X 1 CM SPONGE [33186]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 53276105003
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Adventist Health Commercial |
$13.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$40.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$31.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.39
|
| Rate for Payer: Blue Shield of California Commercial |
$41.84
|
| Rate for Payer: Blue Shield of California EPN |
$26.33
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Central Health Plan Commercial |
$52.80
|
| Rate for Payer: Cigna of CA HMO |
$42.24
|
| Rate for Payer: Cigna of CA PPO |
$48.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$56.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$46.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.40
|
| Rate for Payer: EPIC Health Plan Senior |
$26.40
|
| Rate for Payer: Galaxy Health WC |
$56.10
|
| Rate for Payer: Global Benefits Group Commercial |
$39.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$59.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$41.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$38.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$46.20
|
| Rate for Payer: Multiplan Commercial |
$49.50
|
| Rate for Payer: Networks By Design Commercial |
$42.90
|
| Rate for Payer: Prime Health Services Commercial |
$56.10
|
| Rate for Payer: Riverside University Health System MISP |
$26.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$39.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$39.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.00
|
| Rate for Payer: United Healthcare All Other HMO |
$33.00
|
| Rate for Payer: United Healthcare HMO Rider |
$33.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.10
|
| Rate for Payer: Vantage Medical Group Senior |
$56.10
|
|
|
MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 69990
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$63.40 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$63.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$70.03
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
MIDAZOLAM 1 MG/ML INJECTION SOLUTION (PF/NON-PF WRAP) [40893519]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
MIDAZOLAM 1 MG/ML INJECTION SOLUTION (PF/NON-PF WRAP) [40893519]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 0054356699
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Senior |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.12
|
| Rate for Payer: Riverside University Health System MISP |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.12
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 6809476459
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Riverside University Health System MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 0054356699
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Senior |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.12
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 6809476462
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Riverside University Health System MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 6809476462
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
|
