|
MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0816-49
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0816-49
|
| 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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$32.66
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$27.76 |
| Rate for Payer: Adventist Health Commercial |
$6.53
|
| Rate for Payer: Adventist Health Commercial |
$9.36
|
| Rate for Payer: Adventist Health Commercial |
$17.95
|
| Rate for Payer: Adventist Health Commercial |
$22.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$67.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cash Price |
$61.71
|
| Rate for Payer: Cash Price |
$17.97
|
| Rate for Payer: Cash Price |
$17.97
|
| Rate for Payer: Cash Price |
$61.71
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.78
|
| Rate for Payer: Dignity Health Senior |
$39.78
|
| Rate for Payer: Dignity Health Senior |
$76.30
|
| Rate for Payer: Dignity Health Senior |
$27.76
|
| Rate for Payer: Dignity Health Senior |
$95.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.56
|
| Rate for Payer: Heritage Provider Network Senior |
$41.56
|
| Rate for Payer: Heritage Provider Network Senior |
$51.95
|
| Rate for Payer: Heritage Provider Network Senior |
$15.12
|
| Rate for Payer: Heritage Provider Network Senior |
$21.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.83
|
| Rate for Payer: Multiplan Commercial |
$67.32
|
| Rate for Payer: Multiplan Commercial |
$24.50
|
| Rate for Payer: Multiplan Commercial |
$35.10
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.06
|
| Rate for Payer: TriValley Medical Group Senior |
$35.90
|
| Rate for Payer: TriValley Medical Group Senior |
$13.06
|
| Rate for Payer: TriValley Medical Group Senior |
$44.88
|
| Rate for Payer: TriValley Medical Group Senior |
$18.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.30
|
| Rate for Payer: Vantage Medical Group Senior |
$95.37
|
| Rate for Payer: Vantage Medical Group Senior |
$27.76
|
| Rate for Payer: Vantage Medical Group Senior |
$39.78
|
| Rate for Payer: Vantage Medical Group Senior |
$76.30
|
|
|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
IP
|
$89.76
|
|
|
Service Code
|
HCPCS J2247
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$67.32 |
| Rate for Payer: Adventist Health Commercial |
$17.95
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.56
|
| Rate for Payer: Heritage Provider Network Senior |
$41.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.44
|
| Rate for Payer: Multiplan Commercial |
$67.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.72
|
|
|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
OP
|
$89.76
|
|
|
Service Code
|
HCPCS J2247
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$76.30 |
| Rate for Payer: Adventist Health Commercial |
$17.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$67.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.53
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.30
|
| Rate for Payer: Dignity Health Senior |
$76.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.56
|
| Rate for Payer: Heritage Provider Network Senior |
$41.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.83
|
| Rate for Payer: Multiplan Commercial |
$67.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.90
|
| Rate for Payer: TriValley Medical Group Senior |
$35.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.30
|
| Rate for Payer: Vantage Medical Group Senior |
$76.30
|
|
|
MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]
|
Facility
|
IP
|
$46.80
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Adventist Health Commercial |
$9.36
|
| Rate for Payer: Adventist Health Commercial |
$17.95
|
| Rate for Payer: Adventist Health Commercial |
$22.44
|
| Rate for Payer: Adventist Health Commercial |
$6.53
|
| Rate for Payer: Cash Price |
$17.97
|
| Rate for Payer: Cash Price |
$25.74
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cash Price |
$61.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.95
|
| Rate for Payer: Heritage Provider Network Senior |
$41.56
|
| Rate for Payer: Heritage Provider Network Senior |
$51.95
|
| Rate for Payer: Heritage Provider Network Senior |
$15.12
|
| Rate for Payer: Heritage Provider Network Senior |
$21.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: Multiplan Commercial |
$67.32
|
| Rate for Payer: Multiplan Commercial |
$35.10
|
| Rate for Payer: Multiplan Commercial |
$24.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.15
|
|
|
MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY [10603]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 61269-736-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| 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 |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
IP
|
$11.75
|
|
|
Service Code
|
NDC 24385-606-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Adventist Health Commercial |
$2.35
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.95
|
| Rate for Payer: Heritage Provider Network Senior |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
OP
|
$11.75
|
|
|
Service Code
|
NDC 24385-606-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$9.99 |
| Rate for Payer: Adventist Health Commercial |
$2.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.81
|
| Rate for Payer: Blue Shield of California Commercial |
$7.17
|
| Rate for Payer: Blue Shield of California EPN |
$5.73
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.99
|
| Rate for Payer: Dignity Health Senior |
$9.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.27
|
| Rate for Payer: Heritage Provider Network Senior |
$7.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.22
|
| Rate for Payer: Multiplan Commercial |
$8.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.70
|
| Rate for Payer: TriValley Medical Group Senior |
$4.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.99
|
| Rate for Payer: Vantage Medical Group Senior |
$9.99
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 0472-1738-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: Adventist Health Commercial |
$3.82
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.93
|
| Rate for Payer: Heritage Provider Network Senior |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
NDC 0472-1738-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Adventist Health Commercial |
$3.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.32
|
| Rate for Payer: Blue Shield of California Commercial |
$11.65
|
| Rate for Payer: Blue Shield of California EPN |
$9.32
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.23
|
| Rate for Payer: Dignity Health Senior |
$16.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.82
|
| Rate for Payer: Heritage Provider Network Senior |
$11.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.37
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.64
|
| Rate for Payer: TriValley Medical Group Senior |
$7.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.23
|
| Rate for Payer: Vantage Medical Group Senior |
$16.23
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0536-1375-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.10
|
|
|
Service Code
|
NDC 61269-735-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 68001-481-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [5039]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 61269-735-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 68001-481-47
|
| 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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.18
|
|
|
Service Code
|
NDC 0536-1375-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0316-0225-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL POWDER [10599]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0316-0225-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| 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: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 51672-2035-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0904-7734-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5040]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 51672-2035-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| 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: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.19
|
|
|
Service Code
|
NDC 8770179251
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
