|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 0713-0678-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 45802-059-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 45802-059-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 45802-059-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 0713-0678-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 45802-048-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
NDC 72578-089-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
NDC 72578-089-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 45802-048-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$1.55
|
|
|
Service Code
|
NDC 69315-306-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0574-2008-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0574-2008-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 42806-186-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 68308-152-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 68308-152-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
NDC 69315-306-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 42806-186-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0574-2008-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0574-2008-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 0121-1045-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0121-0868-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0121-0868-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0121-0868-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0121-0868-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 0121-0868-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
