|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
OP
|
$12.02
|
|
|
Service Code
|
NDC 66689003799
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$11.42 |
| Rate for Payer: Aetna Commercial |
$10.82
|
| Rate for Payer: Humana Medicare Advantage |
$5.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.81
|
| Rate for Payer: WPPA Medicare Advantage |
$7.21
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
IP
|
$12.02
|
|
|
Service Code
|
NDC 66689003799
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.42
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
OP
|
$13.39
|
|
|
Service Code
|
NDC 68094059962
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Aetna Commercial |
$12.05
|
| Rate for Payer: Humana Medicare Advantage |
$5.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.36
|
| Rate for Payer: WPPA Medicare Advantage |
$8.03
|
|
|
nystatin 100000 units/mL Sus 60 mL TH [HMC]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 69315050460
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$30.02 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Humana Medicare Advantage |
$13.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.64
|
| Rate for Payer: WPPA Medicare Advantage |
$18.96
|
|
|
nystatin 100000 units/mL Sus 60 mL TH [HMC]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 69315050460
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100000 units/mL Sus 60 mL TH [HMC]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 00121086802
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$30.02 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Humana Medicare Advantage |
$13.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.64
|
| Rate for Payer: WPPA Medicare Advantage |
$18.96
|
|
|
nystatin 100000 units/mL Sus 60 mL TH [HMC]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 00121086802
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100000 units/mL Sus 60 mL TH [HMC]
|
Facility
|
IP
|
$31.60
|
|
|
Service Code
|
NDC 66689000802
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100000 units/mL Sus 60 mL TH [HMC]
|
Facility
|
OP
|
$31.60
|
|
|
Service Code
|
NDC 66689000802
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$30.02 |
| Rate for Payer: Aetna Commercial |
$28.44
|
| Rate for Payer: Humana Medicare Advantage |
$13.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.64
|
| Rate for Payer: WPPA Medicare Advantage |
$18.96
|
|
|
nystatin Top 100,000 units/g Crm [HMC]
|
Facility
|
OP
|
$55.55
|
|
|
Service Code
|
NDC 51672128902
|
| Hospital Charge Code |
3800009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.22 |
| Max. Negotiated Rate |
$52.77 |
| Rate for Payer: Aetna Commercial |
$49.99
|
| Rate for Payer: Humana Medicare Advantage |
$23.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.22
|
| Rate for Payer: WPPA Medicare Advantage |
$33.33
|
|
|
nystatin Top 100,000 units/g Crm [HMC]
|
Facility
|
IP
|
$55.44
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
3800009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$49.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.67
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Crm [HMC]
|
Facility
|
IP
|
$55.55
|
|
|
Service Code
|
NDC 51672128902
|
| Hospital Charge Code |
3800009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.99 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$49.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Crm [HMC]
|
Facility
|
OP
|
$55.44
|
|
|
Service Code
|
NDC 45802005911
|
| Hospital Charge Code |
3800009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.18 |
| Max. Negotiated Rate |
$52.67 |
| Rate for Payer: Aetna Commercial |
$49.90
|
| Rate for Payer: Humana Medicare Advantage |
$23.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.18
|
| Rate for Payer: WPPA Medicare Advantage |
$33.26
|
|
|
nystatin top 100000 units/g Pwdr [HMC]
|
Facility
|
OP
|
$28.28
|
|
|
Service Code
|
NDC 69315030615
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$26.87 |
| Rate for Payer: Aetna Commercial |
$25.45
|
| Rate for Payer: Humana Medicare Advantage |
$11.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.31
|
| Rate for Payer: WPPA Medicare Advantage |
$16.97
|
|
|
nystatin top 100000 units/g Pwdr [HMC]
|
Facility
|
IP
|
$28.28
|
|
|
Service Code
|
NDC 69315030615
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.45 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
OP
|
$26.95
|
|
|
Service Code
|
NDC 68308015215
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Aetna Commercial |
$24.25
|
| Rate for Payer: Humana Medicare Advantage |
$11.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.78
|
| Rate for Payer: WPPA Medicare Advantage |
$16.17
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
IP
|
$25.34
|
|
|
Service Code
|
NDC 68308015230
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.07
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
IP
|
$42.46
|
|
|
Service Code
|
NDC 00832046515
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$38.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.34
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
OP
|
$28.28
|
|
|
Service Code
|
NDC 69315030630
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$26.87 |
| Rate for Payer: Aetna Commercial |
$25.45
|
| Rate for Payer: Humana Medicare Advantage |
$11.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.31
|
| Rate for Payer: WPPA Medicare Advantage |
$16.97
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
IP
|
$26.95
|
|
|
Service Code
|
NDC 68308015215
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.60
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
OP
|
$32.46
|
|
|
Service Code
|
NDC 00574200815
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.98 |
| Max. Negotiated Rate |
$30.84 |
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: Humana Medicare Advantage |
$13.63
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.98
|
| Rate for Payer: WPPA Medicare Advantage |
$19.48
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
OP
|
$25.34
|
|
|
Service Code
|
NDC 68308015230
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$24.07 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: Humana Medicare Advantage |
$10.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.14
|
| Rate for Payer: WPPA Medicare Advantage |
$15.20
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
IP
|
$28.28
|
|
|
Service Code
|
NDC 69315030630
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.45 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
OP
|
$37.68
|
|
|
Service Code
|
NDC 00832046560
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$33.91
|
| Rate for Payer: Humana Medicare Advantage |
$15.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.07
|
| Rate for Payer: WPPA Medicare Advantage |
$22.61
|
|
|
nystatin Top 100,000 units/g Pwdr [HMC]
|
Facility
|
IP
|
$32.46
|
|
|
Service Code
|
NDC 00574200815
|
| Hospital Charge Code |
3802861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.84
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
