|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| 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: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.41
|
| 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 |
$3.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: Multiplan Commercial |
$2.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.01
|
| 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 |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Vantage Medical Group Senior |
$3.15
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
| 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 |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
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 |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| 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 |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| 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: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.28 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.94
|
| 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 |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| 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: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| 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: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| 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: Aetna of CA Non-Gatekeeper |
$2.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.96
|
| 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 |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| 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: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$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 |
$1.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Senior |
$0.45
|
| Rate for Payer: TriValley Medical Group Senior |
$1.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.03
|
| 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 Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| 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
|
$1.21
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| 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: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.14
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.10
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| 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: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| 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: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| 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 |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
|
|
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 |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$2.59
|
|
|
Service Code
|
NDC 5167240266
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.67
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 3557343330
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| 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 |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| 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: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$2.66
|
|
|
Service Code
|
NDC 5167240261
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.71
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Senior |
$1.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 3557343330
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
KETOCONAZOLE 200 MG TABLET [10369]
|
Facility
|
OP
|
$2.66
|
|
|
Service Code
|
NDC 5167240261
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| 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 |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California EPN |
$1.30
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.73
|
| 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: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Senior |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.06
|
| Rate for Payer: TriValley Medical Group Senior |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$2.59
|
|
|
Service Code
|
NDC 5167240266
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| 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 |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.68
|
| 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: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Senior |
$1.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 2 % SHAMPOO [14132]
|
Facility
|
OP
|
$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: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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 |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
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 |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
OP
|
$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: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
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 |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 5167212982
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM [10368]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 0168009930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
