|
NUTREN 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716006220
|
| Hospital Charge Code |
200082
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716016220
|
| Hospital Charge Code |
200082
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 1.5 INTERMITTENT FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 98716006220
|
| Hospital Charge Code |
200082
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.89
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 BOLUS FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
150720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.89
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
150720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 CONTINUOUS FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
168944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.89
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
168944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 CYCLIC FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
200085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.89
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 CYCLIC FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
200085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 INTERMITTENT FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
200084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.89
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NUTREN 2.0 INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
200084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: ASR Commercial |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$18.09
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$18.09 |
| Rate for Payer: Aetna Commercial |
$16.28
|
| Rate for Payer: Aetna Medicare |
$9.04
|
| Rate for Payer: ASR ASR |
$17.55
|
| Rate for Payer: ASR Commercial |
$17.55
|
| Rate for Payer: BCBS Complete |
$7.24
|
| Rate for Payer: BCBS Trust/PPO |
$14.81
|
| Rate for Payer: BCN Commercial |
$14.03
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cofinity Commercial |
$17.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.47
|
| Rate for Payer: Healthscope Commercial |
$18.09
|
| Rate for Payer: Healthscope Whirlpool |
$17.55
|
| Rate for Payer: Mclaren Commercial |
$16.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.38
|
| Rate for Payer: Nomi Health Commercial |
$14.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.85
|
| Rate for Payer: Priority Health Narrow Network |
$12.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.92
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$42.52
|
|
|
Service Code
|
NDC 51672128902
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.64 |
| Max. Negotiated Rate |
$42.52 |
| Rate for Payer: Aetna Commercial |
$38.27
|
| Rate for Payer: ASR ASR |
$41.24
|
| Rate for Payer: ASR Commercial |
$41.24
|
| Rate for Payer: BCBS Trust/PPO |
$34.65
|
| Rate for Payer: BCN Commercial |
$32.97
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cofinity Commercial |
$39.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.02
|
| Rate for Payer: Healthscope Commercial |
$42.52
|
| Rate for Payer: Healthscope Whirlpool |
$41.24
|
| Rate for Payer: Mclaren Commercial |
$38.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.14
|
| Rate for Payer: Nomi Health Commercial |
$34.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$65.10
|
|
|
Service Code
|
NDC 00713067831
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna Commercial |
$58.59
|
| Rate for Payer: ASR ASR |
$63.15
|
| Rate for Payer: ASR Commercial |
$63.15
|
| Rate for Payer: BCBS Trust/PPO |
$53.05
|
| Rate for Payer: BCN Commercial |
$50.47
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Healthscope Commercial |
$65.10
|
| Rate for Payer: Healthscope Whirlpool |
$63.15
|
| Rate for Payer: Mclaren Commercial |
$58.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: Nomi Health Commercial |
$53.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.29
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$65.10
|
|
|
Service Code
|
NDC 00713067831
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna Commercial |
$58.59
|
| Rate for Payer: Aetna Medicare |
$32.55
|
| Rate for Payer: ASR ASR |
$63.15
|
| Rate for Payer: ASR Commercial |
$63.15
|
| Rate for Payer: BCBS Complete |
$26.04
|
| Rate for Payer: BCBS Trust/PPO |
$53.31
|
| Rate for Payer: BCN Commercial |
$50.47
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Healthscope Commercial |
$65.10
|
| Rate for Payer: Healthscope Whirlpool |
$63.15
|
| Rate for Payer: Mclaren Commercial |
$58.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: Nomi Health Commercial |
$53.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$57.04
|
| Rate for Payer: Priority Health Narrow Network |
$45.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.29
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$42.52
|
|
|
Service Code
|
NDC 51672128902
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.01 |
| Max. Negotiated Rate |
$42.52 |
| Rate for Payer: Aetna Commercial |
$38.27
|
| Rate for Payer: Aetna Medicare |
$21.26
|
| Rate for Payer: ASR ASR |
$41.24
|
| Rate for Payer: ASR Commercial |
$41.24
|
| Rate for Payer: BCBS Complete |
$17.01
|
| Rate for Payer: BCBS Trust/PPO |
$34.82
|
| Rate for Payer: BCN Commercial |
$32.97
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cofinity Commercial |
$39.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.02
|
| Rate for Payer: Healthscope Commercial |
$42.52
|
| Rate for Payer: Healthscope Whirlpool |
$41.24
|
| Rate for Payer: Mclaren Commercial |
$38.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.14
|
| Rate for Payer: Nomi Health Commercial |
$34.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.26
|
| Rate for Payer: Priority Health Narrow Network |
$29.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$24.99
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.24 |
| Max. Negotiated Rate |
$24.99 |
| Rate for Payer: Aetna Commercial |
$22.49
|
| Rate for Payer: ASR ASR |
$24.24
|
| Rate for Payer: ASR Commercial |
$24.24
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$19.37
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cofinity Commercial |
$23.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.99
|
| Rate for Payer: Healthscope Commercial |
$24.99
|
| Rate for Payer: Healthscope Whirlpool |
$24.24
|
| Rate for Payer: Mclaren Commercial |
$22.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.24
|
| Rate for Payer: Nomi Health Commercial |
$20.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.99
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$18.09
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$18.09 |
| Rate for Payer: Aetna Commercial |
$16.28
|
| Rate for Payer: ASR ASR |
$17.55
|
| Rate for Payer: ASR Commercial |
$17.55
|
| Rate for Payer: BCBS Trust/PPO |
$14.74
|
| Rate for Payer: BCN Commercial |
$14.03
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cofinity Commercial |
$17.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.47
|
| Rate for Payer: Healthscope Commercial |
$18.09
|
| Rate for Payer: Healthscope Whirlpool |
$17.55
|
| Rate for Payer: Mclaren Commercial |
$16.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.38
|
| Rate for Payer: Nomi Health Commercial |
$14.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.92
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$24.99
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$24.99 |
| Rate for Payer: Aetna Commercial |
$22.49
|
| Rate for Payer: Aetna Medicare |
$12.49
|
| Rate for Payer: ASR ASR |
$24.24
|
| Rate for Payer: ASR Commercial |
$24.24
|
| Rate for Payer: BCBS Complete |
$10.00
|
| Rate for Payer: BCBS Trust/PPO |
$20.46
|
| Rate for Payer: BCN Commercial |
$19.37
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cofinity Commercial |
$23.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.99
|
| Rate for Payer: Healthscope Commercial |
$24.99
|
| Rate for Payer: Healthscope Whirlpool |
$24.24
|
| Rate for Payer: Mclaren Commercial |
$22.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.24
|
| Rate for Payer: Nomi Health Commercial |
$20.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.90
|
| Rate for Payer: Priority Health Narrow Network |
$17.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.99
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
OP
|
$6.48
|
|
|
Service Code
|
NDC 00121086805
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna Commercial |
$5.83
|
| Rate for Payer: Aetna Medicare |
$3.24
|
| Rate for Payer: ASR ASR |
$6.29
|
| Rate for Payer: ASR Commercial |
$6.29
|
| Rate for Payer: BCBS Complete |
$2.59
|
| Rate for Payer: BCBS Trust/PPO |
$5.31
|
| Rate for Payer: BCN Commercial |
$5.02
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cofinity Commercial |
$6.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.18
|
| Rate for Payer: Healthscope Commercial |
$6.48
|
| Rate for Payer: Healthscope Whirlpool |
$6.29
|
| Rate for Payer: Mclaren Commercial |
$5.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.51
|
| Rate for Payer: Nomi Health Commercial |
$5.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.68
|
| Rate for Payer: Priority Health Narrow Network |
$4.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.70
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 66689003701
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: ASR ASR |
$5.33
|
| Rate for Payer: ASR Commercial |
$5.33
|
| Rate for Payer: BCBS Trust/PPO |
$4.47
|
| Rate for Payer: BCN Commercial |
$4.26
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$5.49
|
| Rate for Payer: Healthscope Whirlpool |
$5.33
|
| Rate for Payer: Mclaren Commercial |
$4.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.67
|
| Rate for Payer: Nomi Health Commercial |
$4.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.83
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 66689003750
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: ASR ASR |
$5.33
|
| Rate for Payer: ASR Commercial |
$5.33
|
| Rate for Payer: BCBS Trust/PPO |
$4.47
|
| Rate for Payer: BCN Commercial |
$4.26
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$5.49
|
| Rate for Payer: Healthscope Whirlpool |
$5.33
|
| Rate for Payer: Mclaren Commercial |
$4.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.67
|
| Rate for Payer: Nomi Health Commercial |
$4.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.83
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
OP
|
$8.52
|
|
|
Service Code
|
NDC 00121086850
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$8.52 |
| Rate for Payer: Aetna Commercial |
$7.67
|
| Rate for Payer: Aetna Medicare |
$4.26
|
| Rate for Payer: ASR ASR |
$8.26
|
| Rate for Payer: ASR Commercial |
$8.26
|
| Rate for Payer: BCBS Complete |
$3.41
|
| Rate for Payer: BCBS Trust/PPO |
$6.98
|
| Rate for Payer: BCN Commercial |
$6.61
|
| Rate for Payer: Cash Price |
$6.82
|
| Rate for Payer: Cofinity Commercial |
$8.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.82
|
| Rate for Payer: Healthscope Commercial |
$8.52
|
| Rate for Payer: Healthscope Whirlpool |
$8.26
|
| Rate for Payer: Mclaren Commercial |
$7.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.24
|
| Rate for Payer: Nomi Health Commercial |
$6.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.47
|
| Rate for Payer: Priority Health Narrow Network |
$5.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.50
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
OP
|
$5.49
|
|
|
Service Code
|
NDC 66689003750
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna Medicare |
$2.75
|
| Rate for Payer: ASR ASR |
$5.33
|
| Rate for Payer: ASR Commercial |
$5.33
|
| Rate for Payer: BCBS Complete |
$2.20
|
| Rate for Payer: BCBS Trust/PPO |
$4.50
|
| Rate for Payer: BCN Commercial |
$4.26
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$5.49
|
| Rate for Payer: Healthscope Whirlpool |
$5.33
|
| Rate for Payer: Mclaren Commercial |
$4.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.67
|
| Rate for Payer: Nomi Health Commercial |
$4.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.81
|
| Rate for Payer: Priority Health Narrow Network |
$3.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.83
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.52
|
|
|
Service Code
|
NDC 00121086850
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$8.52 |
| Rate for Payer: Aetna Commercial |
$7.67
|
| Rate for Payer: ASR ASR |
$8.26
|
| Rate for Payer: ASR Commercial |
$8.26
|
| Rate for Payer: BCBS Trust/PPO |
$6.94
|
| Rate for Payer: BCN Commercial |
$6.61
|
| Rate for Payer: Cash Price |
$6.82
|
| Rate for Payer: Cofinity Commercial |
$8.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.82
|
| Rate for Payer: Healthscope Commercial |
$8.52
|
| Rate for Payer: Healthscope Whirlpool |
$8.26
|
| Rate for Payer: Mclaren Commercial |
$7.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.24
|
| Rate for Payer: Nomi Health Commercial |
$6.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.50
|
|
