Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$2.00

Service Code	NDC 0409-2051-05
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$2.00

Service Code	NDC 0409-2051-05
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$3.06

Service Code	NDC 0143-9509-10
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.45
Rate for Payer: Cash Price	$1.38
Rate for Payer: Cigna of CA HMO/PPO	$2.45
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.30

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$3.06

Service Code	NDC 0143-9509-01
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.45
Rate for Payer: Cash Price	$1.38
Rate for Payer: Cigna of CA HMO/PPO	$2.45
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.30

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$3.06

Service Code	NDC 0143-9509-01
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.84
Rate for Payer: Aetna of CA Government/Medicare	$1.84
Rate for Payer: Cash Price	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.84
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.30

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$3.06

Service Code	NDC 0143-9509-10
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.84
Rate for Payer: Aetna of CA Government/Medicare	$1.84
Rate for Payer: Cash Price	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.84
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.30

KETAMINE 100 MG/ML INJECTION SOLUTION [4237]

Facility

$2.00

Service Code	NDC 0409-2051-15
Hospital Charge Code	1720437
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]

Facility

$3.20

Service Code	NDC 42023-115-10
Hospital Charge Code	1720437
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.92
Rate for Payer: Aetna of CA Government/Medicare	$1.92
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.40

KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]

Facility

$3.20

Service Code	NDC 42023-115-10
Hospital Charge Code	1720437
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cigna of CA HMO/PPO	$2.56
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.40

KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]

Facility

$1.92

Service Code	NDC 9994-0842-37
Hospital Charge Code	NDC4084237
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

KETAMINE 100 MG/ML ORAL SOLUTION (IV FORM) [4084237]

Facility

$1.92

Service Code	NDC 9994-0842-37
Hospital Charge Code	NDC4084237
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

KETAMINE 10 MG/ML INJECTION SOLUTION [4236]

Facility

$1.16

Service Code	NDC 67457-181-00
Hospital Charge Code	NDG4236
Hospital Revenue Code	250
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.87

KETAMINE 10 MG/ML INJECTION SOLUTION [4236]

Facility

$1.16

Service Code	NDC 67457-181-00
Hospital Charge Code	NDG4236
Hospital Revenue Code	250
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna of CA HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.87

KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]

Facility

$1.52

Service Code	NDC 71286-3022-1
Hospital Charge Code	1737086
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

KETAMINE 10 MG/ML INJECTION SOLUTION WRAP. [40804236]

Facility

$1.52

Service Code	NDC 71286-3022-1
Hospital Charge Code	1737086
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]

Facility

$1.21

Service Code	NDC 70092-9119-44
Hospital Charge Code	1737086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.91

KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]

Facility

$1.21

Service Code	NDC 70092-1119-44
Hospital Charge Code	1737086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.91

KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]

Facility

$1.52

Service Code	NDC 71286-3022-1
Hospital Charge Code	1737086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]

Facility

$1.21

Service Code	NDC 70092-9119-44
Hospital Charge Code	1737086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.97
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.91

KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]

Facility

$1.52

Service Code	NDC 71286-3022-1
Hospital Charge Code	1737086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

KETAMINE 10 MG/ML ORAL SOLN (IV FORM) [4081892]

Facility

$1.21

Service Code	NDC 70092-1119-44
Hospital Charge Code	1737086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.97
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.91

KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]

Facility

$1.52

Service Code	NDC 71286-3022-1
Hospital Charge Code	1737086
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]

Facility

$1.52

Service Code	NDC 71286-3022-1
Hospital Charge Code	1737086
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]

Facility

$1.56

Service Code	NDC 70004-430-09
Hospital Charge Code	1737086
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE [120234]

Facility

$1.56

Service Code	NDC 70004-430-09
Hospital Charge Code	1737086
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

Know your out-of-pocket cost for care.

All Charges