|
NUSINERSEN (PF) 12 MG/5 ML INTRATHECAL SOLUTION [216584]
|
Facility
|
OP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,207.32 |
| Max. Negotiated Rate |
$27,321.33 |
| Rate for Payer: Vantage Medical Group Senior |
$1,466.80
|
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22,512.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,466.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,525.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1,207.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,207.32
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,757.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,466.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,466.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,314.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,333.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$16,866.37
|
| Rate for Payer: Heritage Provider Network Senior |
$16,866.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17,376.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,593.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,533.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,107.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,786.82
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$14,571.38
|
| Rate for Payer: TriValley Medical Group Senior |
$14,571.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,161.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,061.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,466.80
|
|
|
NUSINERSEN (PF) 28 MG/5 ML INTRATHECAL SOLUTION [249076]
|
Facility
|
IP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,593.55 |
| Max. Negotiated Rate |
$27,321.33 |
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23,459.92
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,757.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,671.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$16,866.37
|
| Rate for Payer: Heritage Provider Network Senior |
$16,866.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,593.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,107.11
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,161.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,061.46
|
|
|
NUSINERSEN (PF) 28 MG/5 ML INTRATHECAL SOLUTION [249076]
|
Facility
|
OP
|
$36,428.44
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,207.32 |
| Max. Negotiated Rate |
$27,321.33 |
| Rate for Payer: Adventist Health Commercial |
$7,285.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22,512.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,466.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,525.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1,207.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,207.32
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cash Price |
$16,392.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16,757.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,466.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,466.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,314.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,333.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$16,866.37
|
| Rate for Payer: Heritage Provider Network Senior |
$16,866.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17,376.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,593.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,533.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,107.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,786.82
|
| Rate for Payer: Multiplan Commercial |
$27,321.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$14,571.38
|
| Rate for Payer: TriValley Medical Group Senior |
$14,571.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13,161.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12,061.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,466.80
|
|
|
NUSINERSEN (PF) 50 MG/5 ML INTRATHECAL SOLUTION [249075]
|
Facility
|
OP
|
$65,050.79
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,207.32 |
| Max. Negotiated Rate |
$48,788.09 |
| Rate for Payer: Adventist Health Commercial |
$13,010.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40,201.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,466.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,525.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1,207.32
|
| Rate for Payer: Blue Shield of California EPN |
$1,207.32
|
| Rate for Payer: Cash Price |
$29,272.86
|
| Rate for Payer: Cash Price |
$29,272.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29,923.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,466.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,466.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$41,632.51
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,333.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$30,118.52
|
| Rate for Payer: Heritage Provider Network Senior |
$30,118.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,333.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$31,029.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,774.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,533.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16,262.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,786.82
|
| Rate for Payer: Multiplan Commercial |
$48,788.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$26,020.32
|
| Rate for Payer: TriValley Medical Group Senior |
$26,020.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23,502.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21,538.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,666.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,466.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1,466.80
|
|
|
NUSINERSEN (PF) 50 MG/5 ML INTRATHECAL SOLUTION [249075]
|
Facility
|
IP
|
$65,050.79
|
|
|
Service Code
|
HCPCS J2326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,774.19 |
| Max. Negotiated Rate |
$48,788.09 |
| Rate for Payer: Adventist Health Commercial |
$13,010.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41,892.71
|
| Rate for Payer: Cash Price |
$29,272.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29,923.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$35,127.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$30,118.52
|
| Rate for Payer: Heritage Provider Network Senior |
$30,118.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,774.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16,262.70
|
| Rate for Payer: Multiplan Commercial |
$48,788.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23,502.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21,538.32
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN 6.2 GRAM-300 KCAL/80 GRAM ORAL PWDR PACK [207833]
|
Facility
|
OP
|
$10.98
|
|
|
Service Code
|
NDC 4390045806
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.49
|
| Rate for Payer: Blue Shield of California Commercial |
$6.70
|
| Rate for Payer: Blue Shield of California EPN |
$5.36
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.80
|
| Rate for Payer: Heritage Provider Network Senior |
$6.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.69
|
| Rate for Payer: Multiplan Commercial |
$8.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.39
|
| Rate for Payer: TriValley Medical Group Senior |
$4.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.33
|
| Rate for Payer: Vantage Medical Group Senior |
$9.33
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN 6.2 GRAM-300 KCAL/80 GRAM ORAL PWDR PACK [207833]
|
Facility
|
IP
|
$10.98
|
|
|
Service Code
|
NDC 4390045806
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.23 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.07
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.23
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 4580205911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 4580205935
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Senior |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 5167212892
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$1.04
|
|
|
Service Code
|
NDC 0713067815
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 0713067831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 0713067831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$1.04
|
|
|
Service Code
|
NDC 0713067815
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 4580205935
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.72
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 5167212891
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 5167212892
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 5167212891
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 4580205911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 4580204811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 4580204811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
NDC 7257808904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
NDC 7257808904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0574200830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 6830815215
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
