|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 60687-862-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Adventist Health Commercial |
$2.53
|
| Rate for Payer: Blue Shield of California Commercial |
$9.78
|
| Rate for Payer: Blue Shield of California EPN |
$6.38
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Central Health Plan Commercial |
$10.12
|
| Rate for Payer: Cigna of CA HMO |
$8.86
|
| Rate for Payer: Cigna of CA PPO |
$8.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.06
|
| Rate for Payer: EPIC Health Plan Senior |
$5.06
|
| Rate for Payer: Galaxy Health WC |
$10.75
|
| Rate for Payer: Global Benefits Group Commercial |
$7.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.53
|
| Rate for Payer: Multiplan Commercial |
$9.49
|
| Rate for Payer: Networks By Design Commercial |
$8.22
|
| Rate for Payer: Prime Health Services Commercial |
$10.75
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 62332-679-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.16
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.29
|
| Rate for Payer: Global Benefits Group Commercial |
$1.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.75
|
| Rate for Payer: Prime Health Services Commercial |
$2.29
|
|
|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
|
IP
|
$12.52
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California Commercial |
$9.68
|
| Rate for Payer: Blue Shield of California EPN |
$6.31
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: Central Health Plan Commercial |
$10.02
|
| Rate for Payer: Cigna of CA HMO |
$8.76
|
| Rate for Payer: Cigna of CA PPO |
$8.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.01
|
| Rate for Payer: EPIC Health Plan Senior |
$5.01
|
| Rate for Payer: Galaxy Health WC |
$10.64
|
| Rate for Payer: Global Benefits Group Commercial |
$7.51
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.50
|
| Rate for Payer: Multiplan Commercial |
$9.39
|
| Rate for Payer: Networks By Design Commercial |
$8.14
|
| Rate for Payer: Prime Health Services Commercial |
$10.64
|
|
|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
|
OP
|
$12.52
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.35
|
| Rate for Payer: Blue Shield of California Commercial |
$7.65
|
| Rate for Payer: Blue Shield of California EPN |
$5.00
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: Central Health Plan Commercial |
$10.02
|
| Rate for Payer: Cigna of CA HMO |
$8.76
|
| Rate for Payer: Cigna of CA PPO |
$8.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.01
|
| Rate for Payer: EPIC Health Plan Senior |
$5.01
|
| Rate for Payer: Galaxy Health WC |
$10.64
|
| Rate for Payer: Global Benefits Group Commercial |
$7.51
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.27
|
| Rate for Payer: InnovAge PACE Commercial |
$6.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.76
|
| Rate for Payer: Multiplan Commercial |
$9.39
|
| Rate for Payer: Networks By Design Commercial |
$8.14
|
| Rate for Payer: Prime Health Services Commercial |
$10.64
|
| Rate for Payer: Riverside University Health System MISP |
$5.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.26
|
| Rate for Payer: United Healthcare All Other HMO |
$6.26
|
| Rate for Payer: United Healthcare HMO Rider |
$6.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.64
|
| Rate for Payer: Vantage Medical Group Senior |
$10.64
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.50
|
| Rate for Payer: Cash Price |
$2.73
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.08
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.98
|
| Rate for Payer: Cash Price |
$2.73
|
| 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: Dignity Health Medi-Cal |
$4.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.99
|
| Rate for Payer: EPIC Health Plan Senior |
$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: InnovAge PACE Commercial |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.48
|
| 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: Riverside University Health System 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 Commercial/Exchange |
$4.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.22
|
| Rate for Payer: Vantage Medical Group Senior |
$4.22
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: InnovAge PACE Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Riverside University Health System 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 Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 65219-186-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Networks By Design Commercial |
$1.60
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 65219-186-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.21
|
| Rate for Payer: InnovAge PACE Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Networks By Design Commercial |
$1.60
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
|
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 |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$1.10
|
| 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: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: InnovAge PACE Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| 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 System 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 Commercial/Exchange |
$1.70
|
| 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
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 65219-186-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.21
|
| Rate for Payer: InnovAge PACE Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Networks By Design Commercial |
$1.60
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
|
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 |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Central Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| 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 0409-2051-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$1.10
|
| 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: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: InnovAge PACE Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| 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 System 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 Commercial/Exchange |
$1.70
|
| 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
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| 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 Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.68
|
| 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: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$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: InnovAge PACE Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Riverside University Health System 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 Commercial/Exchange |
$2.60
|
| 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
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Central Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| 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
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 65219-186-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Networks By Design Commercial |
$1.60
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| 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 |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| 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
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| 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 Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.68
|
| 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: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Senior |
$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: InnovAge PACE Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Riverside University Health System 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 Commercial/Exchange |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
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 |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| 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 Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$1.06
|
| 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: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: InnovAge PACE Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.25
|
| Rate for Payer: Prime Health Services Commercial |
$1.63
|
| Rate for Payer: Riverside University Health System 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 Commercial/Exchange |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
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 |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$1.06
|
| 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: EPIC Health Plan Senior |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| 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 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 |
$0.30 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Central Health Plan Commercial |
$1.22
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Senior |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.37
|
| Rate for Payer: InnovAge PACE Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Riverside University Health System MISP |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
KETAMINE 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 |
$0.24 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
|
|
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 |
$0.24 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Central Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Networks By Design Commercial |
$0.77
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
|
