|
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 |
$1.53 |
| Max. Negotiated Rate |
$76.30 |
| Rate for Payer: Adventist Health Commercial |
$17.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.47
|
| 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 |
$3.61
|
| 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 |
$40.39
|
| Rate for Payer: Cash Price |
$40.39
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$42.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$46.80
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$39.78 |
| Rate for Payer: Adventist Health Commercial |
$9.36
|
| Rate for Payer: Adventist Health Commercial |
$6.53
|
| Rate for Payer: Adventist Health Commercial |
$17.95
|
| Rate for Payer: Adventist Health Commercial |
$22.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.78
|
| 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 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 Medi-Cal |
$25.74
|
| 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: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| 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 |
$40.39
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cash Price |
$40.39
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Cash Price |
$50.49
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| 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: Cigna of CA HMO/PPO |
$21.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.30
|
| 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 |
$39.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$76.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.45
|
| 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 |
$29.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.95
|
| Rate for Payer: Heritage Provider Network Senior |
$21.67
|
| Rate for Payer: Heritage Provider Network Senior |
$15.12
|
| Rate for Payer: Heritage Provider Network Senior |
$41.56
|
| Rate for Payer: Heritage Provider Network Senior |
$51.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$22.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$42.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$15.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| 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 |
$8.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$62.83
|
| Rate for Payer: Multiplan Commercial |
$67.32
|
| Rate for Payer: Multiplan Commercial |
$35.10
|
| Rate for Payer: Multiplan Commercial |
$24.50
|
| Rate for Payer: Multiplan Commercial |
$84.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.06
|
| Rate for Payer: TriValley Medical Group Senior |
$13.06
|
| Rate for Payer: TriValley Medical Group Senior |
$35.90
|
| Rate for Payer: TriValley Medical Group Senior |
$18.72
|
| Rate for Payer: TriValley Medical Group Senior |
$44.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.43
|
| 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 |
$16.91
|
| 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: United Healthcare Navigate/Select/Select+ |
$29.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.78
|
| 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 |
$76.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Vantage Medical Group Senior |
$39.78
|
| Rate for Payer: Vantage Medical Group Senior |
$27.76
|
| Rate for Payer: Vantage Medical Group Senior |
$76.30
|
| Rate for Payer: Vantage Medical Group Senior |
$95.37
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
OP
|
$9.82
|
|
|
Service Code
|
NDC 2438560602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$8.35 |
| Rate for Payer: Adventist Health Commercial |
$1.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.91
|
| Rate for Payer: Blue Shield of California Commercial |
$5.99
|
| Rate for Payer: Blue Shield of California EPN |
$4.79
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.08
|
| Rate for Payer: Heritage Provider Network Senior |
$6.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$7.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.93
|
| Rate for Payer: TriValley Medical Group Senior |
$3.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.35
|
| Rate for Payer: Vantage Medical Group Senior |
$8.35
|
|
|
MICONAZOLE NITRATE 200 MG-2 % (9 GRAM) VAGINAL KIT [24855]
|
Facility
|
IP
|
$9.82
|
|
|
Service Code
|
NDC 2438560602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$7.37 |
| Rate for Payer: Adventist Health Commercial |
$1.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.32
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.65
|
| Rate for Payer: Heritage Provider Network Senior |
$6.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$7.37
|
|
|
MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY [111721]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 0472173803
|
| 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: Aetna of CA Non-Gatekeeper |
$12.30
|
| Rate for Payer: Cash Price |
$8.60
|
| 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 Foundation Hospitals 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 0472173803
|
| 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 Non-Gatekeeper |
$11.80
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$9.55
|
| 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 |
$8.60
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$9.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0536137575
|
| 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 Non-Gatekeeper |
$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 HMO/PPO |
$0.09
|
| 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 |
$0.08
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 6126973556
|
| 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: Aetna of CA Non-Gatekeeper |
$0.06
|
| 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 Foundation Hospitals 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 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 Non-Gatekeeper |
$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 HMO/PPO |
$0.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0536137575
|
| 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: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| 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 Foundation Hospitals 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 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 Non-Gatekeeper |
$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 HMO/PPO |
$0.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.10
|
|
|
Service Code
|
NDC 6800148147
|
| 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: Aetna of CA Non-Gatekeeper |
$0.06
|
| 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 Foundation Hospitals 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 POWDER [10599]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0316022530
|
| 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: Aetna of CA Non-Gatekeeper |
$0.05
|
| 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 Foundation Hospitals 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 0316022530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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 HMO/PPO |
$0.04
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| 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: 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
|
$0.20
|
|
|
Service Code
|
NDC 8770179251
|
| 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: Aetna of CA Non-Gatekeeper |
$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 HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| 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: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| 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 |
$0.17
|
| 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
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 2438559029
|
| 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: Aetna of CA Non-Gatekeeper |
$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 HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| 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: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| 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 |
$0.17
|
| 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
|
$0.22
|
|
|
Service Code
|
NDC 5167220356
|
| 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: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 Foundation Hospitals 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
|
$0.22
|
|
|
Service Code
|
NDC 5167220356
|
| 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 Non-Gatekeeper |
$0.14
|
| 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 HMO/PPO |
$0.11
|
| 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 |
$0.10
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.17
|
|
|
Service Code
|
NDC 0904773445
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
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 |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
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 |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
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 |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| 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 HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| 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: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| 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 |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
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 |
$11.95 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: Adventist Health Commercial |
$13.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.79
|
| 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 HMO/PPO |
$33.01
|
| Rate for Payer: Blue Shield of California Commercial |
$40.26
|
| Rate for Payer: Blue Shield of California EPN |
$32.21
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$42.90
|
| 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: EPIC Health Plan Commercial |
$38.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.85
|
| Rate for Payer: Heritage Provider Network Senior |
$40.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$31.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$46.20
|
| Rate for Payer: Multiplan Commercial |
$49.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$33.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
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 |
$11.95 |
| Max. Negotiated Rate |
$49.50 |
| Rate for Payer: Adventist Health Commercial |
$13.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.50
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.68
|
| Rate for Payer: Heritage Provider Network Senior |
$44.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$49.50
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| 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 HMO/PPO |
$2.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| 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: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
