|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 35573-433-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$2.66
|
|
|
Service Code
|
NDC 51672-4026-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.60
|
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$2.59
|
|
|
Service Code
|
NDC 51672-4026-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 35573-433-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$2.66
|
|
|
Service Code
|
NDC 51672-4026-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Cash Price |
$1.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$2.59
|
|
|
Service Code
|
NDC 51672-4026-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 45802-465-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| 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 |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 63646-010-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| 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 |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| 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 Commercial |
$0.15
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 63646-010-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial |
$0.15
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 45802-465-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| 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 |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 51672-1298-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.91
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 0168-0099-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 51672-1298-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
OP
|
$1.67
|
|
|
Service Code
|
NDC 0093-3219-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
IP
|
$1.67
|
|
|
Service Code
|
NDC 0093-3219-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0168-0099-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
KETOCONAZOLE ORAL SUSPENSION COMPOUND 20 MG/ML [4080285]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 9994-0802-85
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
KETOCONAZOLE ORAL SUSPENSION COMPOUND 20 MG/ML [4080285]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 9994-0802-85
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
IP
|
$6.72
|
|
|
Service Code
|
NDC 61314-126-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Cash Price |
$3.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
OP
|
$66.10
|
|
|
Service Code
|
NDC 0023-2181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.35 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$39.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$39.66
|
| Rate for Payer: Cash Price |
$36.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$52.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$39.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$39.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.35
|
| Rate for Payer: Multiplan Commercial |
$49.58
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 42571-137-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
IP
|
$66.10
|
|
|
Service Code
|
NDC 0023-2181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.35 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Cash Price |
$36.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$52.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$39.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.35
|
| Rate for Payer: Multiplan Commercial |
$49.58
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 42571-137-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
OP
|
$6.72
|
|
|
Service Code
|
NDC 61314-126-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.03
|
| Rate for Payer: Cash Price |
$3.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
|
|
KETOROLAC 10 MG TABLET [10371]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 0093-0314-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
|
