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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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	$0.66
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

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	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

KETAMINE 50 MG/ML INJECTION SOLUTION [4238]

Facility

IP

$0.84

Service Code	NDC 67457-001-00
Hospital Charge Code	NDG4238
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

KETAMINE 50 MG/ML INJECTION SOLUTION [4238]

Facility

OP

$0.84

Service Code	NDC 42023-114-10
Hospital Charge Code	NDG4238
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$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	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

KETAMINE 50 MG/ML INJECTION SOLUTION [4238]

Facility

OP

$0.84

Service Code	NDC 67457-001-10
Hospital Charge Code	NDG4238
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

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	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

KETAMINE 50 MG/ML INJECTION SOLUTION [4238]

Facility

OP

$0.84

Service Code	NDC 67457-001-00
Hospital Charge Code	NDG4238
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

KETAMINE INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]

Facility

OP

$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 INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]

Facility

IP

$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 INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]

Facility

IP

$1.16

Service Code	NDC 67457-181-20
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 INFUSION (STRAIGHT DRAW 10 MG/ML) [4081976]

Facility

OP

$1.16

Service Code	NDC 67457-181-20
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

KETOCONAZOLE 200 MG TABLET [10369]

Facility

OP

$2.59

Service Code	NDC 51672-4026-6
Hospital Charge Code	1710264
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$1.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.55
Rate for Payer: Aetna of CA Government/Medicare	$1.55
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Smart Auto/Commercial	$1.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.55
Rate for Payer: LLUH Dept of Risk Management WC	$1.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.94

KETOCONAZOLE 200 MG TABLET [10369]

Facility

IP

$1.26

Service Code	NDC 35573-433-30
Hospital Charge Code	1710264
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.01
Rate for Payer: Cash Price	$0.57
Rate for Payer: Cigna of CA HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

KETOCONAZOLE 200 MG TABLET [10369]

Facility

OP

$1.26

Service Code	NDC 35573-433-30
Hospital Charge Code	1710264
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

KETOCONAZOLE 200 MG TABLET [10369]

Facility

IP

$2.59

Service Code	NDC 51672-4026-6
Hospital Charge Code	1710264
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.07
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA HMO/PPO	$2.07
Rate for Payer: Health Smart Auto/Commercial	$1.55
Rate for Payer: LLUH Dept of Risk Management WC	$1.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.94

KETOCONAZOLE 200 MG TABLET [10369]

Facility

IP

$2.66

Service Code	NDC 51672-4026-1
Hospital Charge Code	1710264
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$2.13
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cigna of CA HMO/PPO	$2.13
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.00

KETOCONAZOLE 200 MG TABLET [10369]

Facility

OP

$2.66

Service Code	NDC 51672-4026-1
Hospital Charge Code	1710264
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.60
Rate for Payer: Aetna of CA Government/Medicare	$1.60
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.00

KETOCONAZOLE 2 % SHAMPOO [14132]

Facility

IP

$0.20

Service Code	NDC 63646-010-04
Hospital Charge Code	1774007
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

KETOCONAZOLE 2 % SHAMPOO [14132]

Facility

IP

$0.22

Service Code	NDC 45802-465-64
Hospital Charge Code	1774007
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

KETOCONAZOLE 2 % SHAMPOO [14132]

Facility

OP

$0.20

Service Code	NDC 63646-010-04
Hospital Charge Code	1774007
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

KETOCONAZOLE 2 % SHAMPOO [14132]

Facility

OP

$0.22

Service Code	NDC 45802-465-64
Hospital Charge Code	1774007
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

KETOCONAZOLE 2 % TOPICAL CREAM [10368]

Facility

OP

$1.52

Service Code	NDC 51672-1298-2
Hospital Charge Code	1743493
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

KETOCONAZOLE 2 % TOPICAL CREAM [10368]

Facility

IP

$1.00

Service Code	NDC 0168-0099-30
Hospital Charge Code	1743493
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

KETOCONAZOLE 2 % TOPICAL CREAM [10368]

Facility

IP

$1.52

Service Code	NDC 51672-1298-2
Hospital Charge Code	1743493
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

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