|
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
|
$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: 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 |
$2.30
|
| 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: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| 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 |
NDC4084237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| 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: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Senior |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: 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 |
NDC4084237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
|
KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 42023-115-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
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 |
$0.58 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California EPN |
$1.88
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [4236]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 67457-181-00
|
| Hospital Charge Code |
NDG4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [4236]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-181-00
|
| Hospital Charge Code |
NDG4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| 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: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Senior |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Senior |
$0.61
|
| 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
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| 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: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Senior |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Senior |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 70092-1119-44
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Senior |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
|
|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 70092-1119-44
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 70092-9119-44
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Senior |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
|
|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 70092-9119-44
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| 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: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Senior |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Senior |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 70004-430-09
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 70004-430-09
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Senior |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 71286-3022-1
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [222821]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [222821]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1737086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 42023-114-10
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 67457-001-10
|
| Hospital Charge Code |
NDG4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
