Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]

Facility

$0.84

Service Code	NDC 45802-048-11
Hospital Charge Code	1743427
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.63

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]

Facility

$0.76

Service Code	NDC 72578-089-04
Hospital Charge Code	1743427
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.57
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	$0.34
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 Beech St/Commercial/PHCS	$0.57

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$0.56

Service Code	NDC 68308-152-15
Hospital Charge Code	1743079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.42

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$0.87

Service Code	NDC 0832-0465-15
Hospital Charge Code	1743079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$0.56

Service Code	NDC 68308-152-15
Hospital Charge Code	1743079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.42
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	$0.25
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 Beech St/Commercial/PHCS	$0.42

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$1.55

Service Code	NDC 0574-2008-15
Hospital Charge Code	1743079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.16
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	$0.70
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 Beech St/Commercial/PHCS	$1.16

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$1.55

Service Code	NDC 0574-2008-15
Hospital Charge Code	1743079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.24
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.16

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$0.87

Service Code	NDC 0832-0465-15
Hospital Charge Code	1743079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.34

Service Code	NDC 68094-599-62
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.33

Service Code	NDC 0121-0868-00
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.33

Service Code	NDC 68094-599-59
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.33

Service Code	NDC 0121-0868-05
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.34

Service Code	NDC 68094-599-62
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.34

Service Code	NDC 0121-0868-40
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.20

Service Code	NDC 66689-037-99
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.34

Service Code	NDC 0121-0868-40
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.33

Service Code	NDC 0121-0868-00
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.20

Service Code	NDC 66689-037-01
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.20

Service Code	NDC 66689-037-99
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.33

Service Code	NDC 0121-0868-05
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.34

Service Code	NDC 0121-0868-50
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.20

Service Code	NDC 66689-037-01
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.33

Service Code	NDC 68094-599-59
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.34

Service Code	NDC 0121-0868-50
Hospital Charge Code	1716066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$5.37

Service Code	NDC 0168-0081-15
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$4.30
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cigna of CA HMO/PPO	$4.30
Rate for Payer: Health Smart Auto/Commercial	$3.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.03

Know your out-of-pocket cost for care.

All Charges