|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 70092-1119-44
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.72
|
| Rate for Payer: Blue Distinction Transplant |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Media |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO |
$0.61
|
| Rate for Payer: United Healthcare HMO Rider |
$0.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| 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
|
$1.56
|
|
|
Service Code
|
NDC 70004-430-09
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Blue Shield of California Commercial |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 70004-430-09
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.93
|
| Rate for Payer: Blue Distinction Transplant |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$1.00
|
| Rate for Payer: Cigna of CA PPO |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Media |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| 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 Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.91
|
| Rate for Payer: Blue Distinction Transplant |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Media |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| 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 Senior |
$1.29
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [222821]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| 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 |
$0.66
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| 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 Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| 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: 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 |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| 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
|
CPT J3490
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| 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: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| 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 |
$0.40
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 67457-001-10
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 67457-001-10
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| 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 |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.55
|
| 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 |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 42023-114-10
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 67457-001-00
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 42023-114-10
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| 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 |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.55
|
| 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 |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 67457-001-00
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| 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 |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| 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 |
$0.55
|
| 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 |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
|
KETAMINE INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 67457-181-20
|
| Hospital Charge Code |
NDG4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Distinction Transplant |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Media |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
KETAMINE INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 67457-181-00
|
| Hospital Charge Code |
NDG4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Distinction Transplant |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Media |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
KETAMINE INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-181-00
|
| Hospital Charge Code |
NDG4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
KETAMINE INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-181-20
|
| Hospital Charge Code |
NDG4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$2.66
|
|
|
Service Code
|
NDC 51672-4026-1
|
| Hospital Charge Code |
1710264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| 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: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$2.26
|
| Rate for Payer: Global Benefits Group Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| 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
|
$2.59
|
|
|
Service Code
|
NDC 51672-4026-6
|
| Hospital Charge Code |
1710264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.20 |
| 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 |
$1.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.54
|
| Rate for Payer: Blue Distinction Transplant |
$1.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| 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 Media |
$2.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.20
|
| Rate for Payer: Global Benefits Group Commercial |
$1.55
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| 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
|
| 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 |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| 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 51672-4026-1
|
| Hospital Charge Code |
1710264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.26 |
| 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 |
$1.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.58
|
| Rate for Payer: Blue Distinction Transplant |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.55
|
| 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 Media |
$2.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$2.26
|
| Rate for Payer: Global Benefits Group Commercial |
$1.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| 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
|
| 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
|
$2.59
|
|
|
Service Code
|
NDC 51672-4026-6
|
| Hospital Charge Code |
1710264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| 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: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.20
|
| Rate for Payer: Global Benefits Group Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| 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
|
$1.26
|
|
|
Service Code
|
NDC 35573-433-30
|
| Hospital Charge Code |
1710264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| 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 |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Distinction Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| 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 Media |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| 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
|
| 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
|
$1.26
|
|
|
Service Code
|
NDC 35573-433-30
|
| Hospital Charge Code |
1710264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| 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: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| 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
|
$0.22
|
|
|
Service Code
|
NDC 45802-465-64
|
| Hospital Charge Code |
1774007
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 63646-010-04
|
| Hospital Charge Code |
1774007
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Distinction Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| 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: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
