|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRS03Z
|
| Min. Negotiated Rate |
$7,368.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,368.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0RRK0KZ
|
| Min. Negotiated Rate |
$19,401.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0RRE07Z
|
| Min. Negotiated Rate |
$19,401.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRJ07Z
|
| Min. Negotiated Rate |
$19,401.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRA009
|
| Min. Negotiated Rate |
$7,368.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,368.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRH0JZ
|
| Min. Negotiated Rate |
$19,401.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SR90KZ
|
| Min. Negotiated Rate |
$19,401.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRA01Z
|
| Min. Negotiated Rate |
$7,368.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,368.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRE00A
|
| Min. Negotiated Rate |
$7,368.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,175.00
|
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,368.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SW93JZ
|
| Min. Negotiated Rate |
$7,368.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,175.00
|
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,368.00
|
|
|
Joint Surgery
|
Facility
IP
|
$22,635.00
|
|
|
Service Code
|
ICD 0SRE00Z
|
| Min. Negotiated Rate |
$7,368.00 |
| Max. Negotiated Rate |
$22,635.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,175.00
|
| Rate for Payer: Blue Shield of California Commercial |
$22,635.00
|
| Rate for Payer: Blue Shield of California EPN |
$19,401.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,368.00
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
NDG111957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
NDG111957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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 |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| 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
|
$9,792.00
|
|
|
Service Code
|
CPT 65756
|
| Min. Negotiated Rate |
$232.89 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| 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 HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: IEHP Medi-Cal |
$232.89
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| 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
|
$9,792.00
|
|
|
Service Code
|
CPT 65730
|
| Min. Negotiated Rate |
$1,742.36 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| 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 HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: IEHP Medi-Cal |
$1,742.36
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| 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
|
$9,792.00
|
|
|
Service Code
|
CPT 65755
|
| Min. Negotiated Rate |
$1,742.36 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| 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 HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: IEHP Medi-Cal |
$1,742.36
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| 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
|
$29,429.97
|
|
|
Service Code
|
CPT 65770
|
| Min. Negotiated Rate |
$348.47 |
| Max. Negotiated Rate |
$29,429.97 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| 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 HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23,234.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$17,038.41
|
| Rate for Payer: Dignity Health Senior |
$15,489.46
|
| Rate for Payer: EPIC Health Plan Medicare |
$15,489.46
|
| Rate for Payer: Humana Medicare |
$15,489.46
|
| Rate for Payer: IEHP Medi-Cal |
$348.47
|
| Rate for Payer: IEHP Medicare Advantage |
$15,489.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29,429.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18,277.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19,516.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19,516.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$17,038.41
|
| Rate for Payer: TriValley Medical Group Senior |
$15,489.46
|
| 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
IP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
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 |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| 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 |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| 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
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| 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 |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| 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 |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| 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 |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Senior |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| 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 |
$0.55 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
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 |
$0.55 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
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 |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| 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 |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Senior |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
