|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
IP
|
$11.36
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
ERX204608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Blue Shield of California Commercial |
$8.52
|
| Rate for Payer: Blue Shield of California EPN |
$6.07
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Central Health Plan Commercial |
$9.09
|
| Rate for Payer: Cigna of CA HMO |
$7.95
|
| Rate for Payer: Cigna of CA PPO |
$7.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.54
|
| Rate for Payer: Galaxy Health WC |
$9.66
|
| Rate for Payer: Global Benefits Group Commercial |
$6.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.27
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: Networks By Design Commercial |
$7.38
|
| Rate for Payer: Prime Health Services Commercial |
$9.66
|
|
|
IVERMECTIN 0.5 % LOTION [196318]
|
Facility
IP
|
$2.79
|
|
|
Service Code
|
NDC 24338-183-04
|
| Hospital Charge Code |
NDG196318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Central Health Plan Commercial |
$2.23
|
| Rate for Payer: Cigna of CA HMO |
$1.95
|
| Rate for Payer: Cigna of CA PPO |
$1.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.37
|
| Rate for Payer: Global Benefits Group Commercial |
$1.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
| Rate for Payer: Networks By Design Commercial |
$1.81
|
| Rate for Payer: Prime Health Services Commercial |
$2.37
|
|
|
IVERMECTIN 0.5 % LOTION [196318]
|
Facility
OP
|
$2.79
|
|
|
Service Code
|
NDC 24338-183-04
|
| Hospital Charge Code |
NDG196318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.65
|
| Rate for Payer: BCBS Transplant Transplant |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Central Health Plan Commercial |
$2.23
|
| Rate for Payer: Cigna of CA HMO |
$1.95
|
| Rate for Payer: Cigna of CA PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.37
|
| Rate for Payer: Global Benefits Group Commercial |
$1.67
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.09
|
| Rate for Payer: IEHP medi-cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
| Rate for Payer: Networks By Design Commercial |
$1.81
|
| Rate for Payer: Prime Health Services Commercial |
$2.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.67
|
| Rate for Payer: Riverside University Health MISP |
$1.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Vantage Medical Group Senior |
$2.37
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
IP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
1712490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$2.65
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Central Health Plan Commercial |
$3.98
|
| Rate for Payer: Cigna of CA HMO |
$3.48
|
| Rate for Payer: Cigna of CA PPO |
$3.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.99
|
| Rate for Payer: Galaxy Health WC |
$4.22
|
| Rate for Payer: Global Benefits Group Commercial |
$2.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.73
|
| Rate for Payer: Networks By Design Commercial |
$3.23
|
| Rate for Payer: Prime Health Services Commercial |
$4.22
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
OP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
1712490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.94
|
| Rate for Payer: BCBS Transplant Transplant |
$2.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.43
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Central Health Plan Commercial |
$3.98
|
| Rate for Payer: Cigna of CA HMO |
$3.48
|
| Rate for Payer: Cigna of CA PPO |
$3.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.99
|
| Rate for Payer: Galaxy Health WC |
$4.22
|
| Rate for Payer: Global Benefits Group Commercial |
$2.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.73
|
| Rate for Payer: IEHP medi-cal |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.73
|
| Rate for Payer: Networks By Design Commercial |
$3.23
|
| Rate for Payer: Prime Health Services Commercial |
$4.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.98
|
| Rate for Payer: Riverside University Health MISP |
$1.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.48
|
| Rate for Payer: United Healthcare All Other HMO |
$2.48
|
| Rate for Payer: United Healthcare HMO Rider |
$2.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.22
|
| Rate for Payer: Vantage Medical Group Senior |
$4.22
|
|
|
IXABEPILONE 45 MG INTRAVENOUS SOLUTION [88653]
|
Facility
IP
|
$6,645.17
|
|
|
Service Code
|
CPT J9207
|
| Hospital Charge Code |
1755731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,329.03 |
| Max. Negotiated Rate |
$5,980.65 |
| Rate for Payer: Blue Shield of California Commercial |
$4,983.88
|
| Rate for Payer: Blue Shield of California EPN |
$3,548.52
|
| Rate for Payer: Cash Price |
$2,990.33
|
| Rate for Payer: Central Health Plan Commercial |
$5,316.14
|
| Rate for Payer: Cigna of CA HMO |
$4,651.62
|
| Rate for Payer: Cigna of CA PPO |
$4,651.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,658.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,658.07
|
| Rate for Payer: Galaxy Health WC |
$5,648.39
|
| Rate for Payer: Global Benefits Group Commercial |
$3,987.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,980.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,432.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,329.03
|
| Rate for Payer: Multiplan Commercial |
$4,983.88
|
| Rate for Payer: Networks By Design Commercial |
$3,322.58
|
| Rate for Payer: Prime Health Services Commercial |
$5,648.39
|
|
|
IXABEPILONE 45 MG INTRAVENOUS SOLUTION [88653]
|
Facility
OP
|
$6,645.17
|
|
|
Service Code
|
CPT J9207
|
| Hospital Charge Code |
1755731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.74 |
| Max. Negotiated Rate |
$5,980.65 |
| Rate for Payer: Adventist Health Medi-Cal |
$128.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$793.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$160.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$140.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$140.88
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$126.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.76
|
| Rate for Payer: BCBS Transplant Transplant |
$3,987.10
|
| Rate for Payer: Blue Shield of California Commercial |
$143.00
|
| Rate for Payer: Blue Shield of California EPN |
$130.00
|
| Rate for Payer: Caremore Medicare Advantage |
$128.07
|
| Rate for Payer: Cash Price |
$2,990.33
|
| Rate for Payer: Cash Price |
$2,990.33
|
| Rate for Payer: Central Health Plan Commercial |
$5,316.14
|
| Rate for Payer: Cigna of CA HMO |
$4,651.62
|
| Rate for Payer: Cigna of CA PPO |
$4,651.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$192.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.90
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$128.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$128.07
|
| Rate for Payer: Galaxy Health WC |
$5,648.39
|
| Rate for Payer: Global Benefits Group Commercial |
$3,987.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,980.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4,983.88
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$210.04
|
| Rate for Payer: IEHP medi-cal |
$211.32
|
| Rate for Payer: IEHP Medicare Advantage |
$128.07
|
| Rate for Payer: Innovage PACE Commercial |
$192.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,432.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$128.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,329.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$171.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$171.62
|
| Rate for Payer: Multiplan Commercial |
$4,983.88
|
| Rate for Payer: Networks By Design Commercial |
$3,322.58
|
| Rate for Payer: Prime Health Services Commercial |
$5,648.39
|
| Rate for Payer: Prime Health Services Medicare |
$135.76
|
| Rate for Payer: Riverside University Health MISP |
$140.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,987.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,987.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,322.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3,322.58
|
| Rate for Payer: United Healthcare HMO Rider |
$3,322.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,322.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$192.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$140.88
|
| Rate for Payer: Vantage Medical Group Senior |
$128.07
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
NDG111957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
NDG111957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
Keratoplasty (corneal transplant); endothelial
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 65756
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,080.00 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,080.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,254.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: Caremore Medicare Advantage |
$5,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,858.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,080.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,331.20
|
| Rate for Payer: IEHP medi-cal |
$8,382.00
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Innovage PACE Commercial |
$7,620.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,080.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,807.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,807.20
|
| Rate for Payer: Prime Health Services Medicare |
$5,384.80
|
| Rate for Payer: Riverside University Health MISP |
$5,588.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 65730
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,080.00 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,080.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,254.00
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$5,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,858.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,080.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,331.20
|
| Rate for Payer: IEHP medi-cal |
$8,382.00
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Innovage PACE Commercial |
$7,620.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,080.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,807.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,807.20
|
| Rate for Payer: Prime Health Services Medicare |
$5,384.80
|
| Rate for Payer: Riverside University Health MISP |
$5,588.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Keratoplasty (corneal transplant); penetrating (in pseudophakia)
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 65755
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,080.00 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,080.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,254.00
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$5,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,858.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,080.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,331.20
|
| Rate for Payer: IEHP medi-cal |
$8,382.00
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Innovage PACE Commercial |
$7,620.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,080.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,807.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,807.20
|
| Rate for Payer: Prime Health Services Medicare |
$5,384.80
|
| Rate for Payer: Riverside University Health MISP |
$5,588.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Keratoprosthesis
|
Facility
OP
|
$27,445.00
|
|
|
Service Code
|
CPT 65770
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,603.71 |
| Max. Negotiated Rate |
$27,445.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,489.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23,234.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17,038.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15,489.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,254.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$21,176.30
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$15,489.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23,234.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,910.77
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$15,489.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$15,489.46
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$25,402.71
|
| Rate for Payer: IEHP medi-cal |
$25,557.61
|
| Rate for Payer: IEHP Medicare Advantage |
$15,489.46
|
| Rate for Payer: Innovage PACE Commercial |
$23,234.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15,489.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,755.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20,755.88
|
| Rate for Payer: Multiplan WC |
$21,176.30
|
| Rate for Payer: Preferred Health Network WC |
$21,608.47
|
| Rate for Payer: Prime Health Services Medicare |
$16,418.83
|
| Rate for Payer: Prime Health Services WC |
$20,960.22
|
| Rate for Payer: Riverside University Health MISP |
$17,038.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,813.00
|
| Rate for Payer: United Healthcare All Other HMO |
$27,445.00
|
| Rate for Payer: United Healthcare HMO Rider |
$17,214.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,742.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23,234.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17,038.41
|
| Rate for Payer: Vantage Medical Group Senior |
$15,489.46
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
OP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: BCBS Transplant Transplant |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.60
|
| Rate for Payer: Cigna of CA HMO |
$1.28
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.50
|
| Rate for Payer: IEHP medi-cal |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: Riverside University Health MISP |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
OP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: BCBS Transplant Transplant |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.60
|
| Rate for Payer: Cigna of CA HMO |
$1.28
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.50
|
| Rate for Payer: IEHP medi-cal |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: Riverside University Health MISP |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Central Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
OP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-01
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: BCBS Transplant Transplant |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: Cigna of CA HMO |
$1.96
|
| Rate for Payer: Cigna of CA PPO |
$2.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.30
|
| Rate for Payer: IEHP medi-cal |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Riverside University Health MISP |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.53
|
| Rate for Payer: United Healthcare All Other HMO |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
OP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: BCBS Transplant Transplant |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: Cigna of CA HMO |
$1.96
|
| Rate for Payer: Cigna of CA PPO |
$2.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.30
|
| Rate for Payer: IEHP medi-cal |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Riverside University Health MISP |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.53
|
| Rate for Payer: United Healthcare All Other HMO |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
IP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-01
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Blue Shield of California Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
IP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Blue Shield of California Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
IP
|
$3.20
|
|
|
Service Code
|
NDC 42023-115-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.71
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
OP
|
$3.20
|
|
|
Service Code
|
NDC 42023-115-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.89
|
| Rate for Payer: BCBS Transplant Transplant |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.40
|
| Rate for Payer: IEHP medi-cal |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: Riverside University Health MISP |
$1.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
IP
|
$1.92
|
|
|
Service Code
|
NDC 9994-0842-37
|
| Hospital Charge Code |
NDC4084237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
OP
|
$1.92
|
|
|
Service Code
|
NDC 9994-0842-37
|
| Hospital Charge Code |
NDC4084237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| Rate for Payer: Cigna of CA HMO |
$1.34
|
| Rate for Payer: Cigna of CA PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| Rate for Payer: IEHP medi-cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: Riverside University Health MISP |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO |
$0.96
|
| Rate for Payer: United Healthcare HMO Rider |
$0.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
