NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$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
|
OP
|
$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
|
IP
|
$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
|
IP
|
$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
|
OP
|
$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
|
OP
|
$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
|
IP
|
$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
|
OP
|
$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
|
OP
|
$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
|
IP
|
$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
|
OP
|
$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
|
OP
|
$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
|
IP
|
$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
|
IP
|
$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
|
OP
|
$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
|
OP
|
$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
|
OP
|
$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
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
OP
|
$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
|
OP
|
$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
|
IP
|
$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
|
IP
|
$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
|
IP
|
$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
|
|