|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 65219-186-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.48
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 65219-186-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 9994-0842-37
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.15
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 9994-0842-37
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 65219-184-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 65219-184-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 9940-8202-37
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 9940-8202-37
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.91
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 65219-184-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 65219-184-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 70092-1119-44
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 70092-1119-44
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 9999-1202-34
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 9940-8202-37
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 9940-8202-37
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 9999-1202-34
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
|
|
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 |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
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 |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 42023-114-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 42023-114-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
