|
IXABEPILONE 45 MG INTRAVENOUS SOLUTION [88653]
|
Facility
|
IP
|
$7,252.42
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,450.48 |
| Max. Negotiated Rate |
$6,164.56 |
| Rate for Payer: Adventist Health Commercial |
$1,450.48
|
| Rate for Payer: Blue Shield of California Commercial |
$3,676.98
|
| Rate for Payer: Blue Shield of California Commercial |
$5,577.11
|
| Rate for Payer: Cash Price |
$3,263.59
|
| Rate for Payer: Cigna of CA HMO |
$5,076.69
|
| Rate for Payer: Cigna of CA PPO |
$5,076.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,076.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,900.97
|
| Rate for Payer: EPIC Health Plan Senior |
$2,900.97
|
| Rate for Payer: Galaxy Health WC |
$6,164.56
|
| Rate for Payer: Global Benefits Group Commercial |
$4,351.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,605.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,278.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,740.58
|
| Rate for Payer: Multiplan Commercial |
$5,801.94
|
| Rate for Payer: Networks By Design Commercial |
$3,626.21
|
| Rate for Payer: Prime Health Services Commercial |
$6,164.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,721.83
|
| Rate for Payer: United Healthcare All Other HMO |
$2,649.31
|
| Rate for Payer: United Healthcare HMO Rider |
$2,592.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,375.17
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO |
$2.60
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$2.60
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$1.48
|
| Rate for Payer: Galaxy Health WC |
$3.15
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Global Benefits Group Commercial |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Multiplan Commercial |
$2.97
|
| Rate for Payer: Networks By Design Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.85
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$1.12
|
| Rate for Payer: United Healthcare HMO Rider |
$1.09
|
| Rate for Payer: United Healthcare HMO Rider |
$1.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: United Healthcare HMO Rider |
$1.09
|
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.78
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA HMO |
$2.60
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$2.60
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$1.48
|
| Rate for Payer: Galaxy Health WC |
$3.15
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Global Benefits Group Commercial |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.45
|
| Rate for Payer: Multiplan Commercial |
$2.97
|
| Rate for Payer: Networks By Design Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Networks By Design Commercial |
$1.85
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$3.15
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$1.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$3.15
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 9994084237
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 9994084237
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.23
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.63
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO |
$0.96
|
| Rate for Payer: United Healthcare HMO Rider |
$0.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.76
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.14
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.76
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
KETAMINE 10 MG/ML IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS SOLUTION [234353]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
|
|
KETAMINE 10 MG/ML IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS SOLUTION [234353]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$1.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$1.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$1.03
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$1.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO |
$1.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [222821]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [222821]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| 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: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| 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
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$2.66
|
|
|
Service Code
|
NDC 5167240261
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$2.05
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.86
|
| Rate for Payer: Cigna of CA PPO |
$1.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: EPIC Health Plan Senior |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$2.26
|
| Rate for Payer: Global Benefits Group Commercial |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: Networks By Design Commercial |
$1.73
|
| Rate for Payer: Prime Health Services Commercial |
$2.26
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 3557343330
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$2.59
|
|
|
Service Code
|
NDC 5167240266
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.99
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.81
|
| Rate for Payer: Cigna of CA PPO |
$1.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.20
|
| Rate for Payer: Global Benefits Group Commercial |
$1.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
| Rate for Payer: Networks By Design Commercial |
$1.68
|
| Rate for Payer: Prime Health Services Commercial |
$2.20
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$2.59
|
|
|
Service Code
|
NDC 5167240266
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.81
|
| Rate for Payer: Cigna of CA PPO |
$1.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.20
|
| Rate for Payer: Global Benefits Group Commercial |
$1.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
| Rate for Payer: Networks By Design Commercial |
$1.68
|
| Rate for Payer: Prime Health Services Commercial |
$2.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.29
|
| Rate for Payer: United Healthcare All Other HMO |
$1.29
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2.20
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$2.66
|
|
|
Service Code
|
NDC 5167240261
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.71
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.86
|
| Rate for Payer: Cigna of CA PPO |
$1.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: EPIC Health Plan Senior |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$2.26
|
| Rate for Payer: Global Benefits Group Commercial |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$2.13
|
| Rate for Payer: Networks By Design Commercial |
$1.73
|
| Rate for Payer: Prime Health Services Commercial |
$2.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.33
|
| Rate for Payer: United Healthcare All Other HMO |
$1.33
|
| Rate for Payer: United Healthcare HMO Rider |
$1.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2.26
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 3557343330
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 6364601004
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 4580246564
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
