Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ABACAVIR 20 MG/ML ORAL SOLUTION [24439]

Facility

$0.63

Service Code	NDC 31722-562-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

ABACAVIR 20 MG/ML ORAL SOLUTION [24439]

Facility

$0.63

Service Code	NDC 31722-562-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

ABACAVIR 300 MG TABLET [24438]

Facility

$3.00

Service Code	NDC 31722-557-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Commercial	$2.25

ABACAVIR 300 MG TABLET [24438]

Facility

$10.59

Service Code	NDC 68084-021-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$8.47
Rate for Payer: Cash Price	$5.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.47
Rate for Payer: Health Smart Auto/Commercial	$6.35
Rate for Payer: LLUH Dept of Risk Management WC	$5.82
Rate for Payer: Multiplan Commercial	$7.94

ABACAVIR 300 MG TABLET [24438]

Facility

$10.59

Service Code	NDC 68084-021-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$8.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.35
Rate for Payer: Aetna of CA Government/Medicare	$6.35
Rate for Payer: Cash Price	$5.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.47
Rate for Payer: Health Smart Auto/Commercial	$6.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.35
Rate for Payer: LLUH Dept of Risk Management WC	$5.82
Rate for Payer: Multiplan Commercial	$7.94

ABACAVIR 300 MG TABLET [24438]

Facility

$3.00

Service Code	NDC 31722-557-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Commercial	$2.25

ABACAVIR 600 MG-DOLUTEGRAVIR 50 MG-LAMIVUDINE 300 MG TABLET [207101]

Facility

$155.90

Service Code	NDC 49702-231-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$85.75
Max. Negotiated Rate	$124.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$93.54
Rate for Payer: Aetna of CA Government/Medicare	$93.54
Rate for Payer: Cash Price	$85.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$124.72
Rate for Payer: Health Smart Auto/Commercial	$93.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$93.54
Rate for Payer: LLUH Dept of Risk Management WC	$85.75
Rate for Payer: Multiplan Commercial	$116.92

ABACAVIR 600 MG-DOLUTEGRAVIR 50 MG-LAMIVUDINE 300 MG TABLET [207101]

Facility

$155.90

Service Code	NDC 49702-231-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$85.75
Max. Negotiated Rate	$124.72
Rate for Payer: Cash Price	$85.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$124.72
Rate for Payer: Health Smart Auto/Commercial	$93.54
Rate for Payer: LLUH Dept of Risk Management WC	$85.75
Rate for Payer: Multiplan Commercial	$116.92

ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET [39301]

Facility

$4.00

Service Code	NDC 69097-362-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$2.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET [39301]

Facility

$4.00

Service Code	NDC 69097-362-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$2.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

ABEMACICLIB 100 MG TABLET [219901]

Facility

$349.93

Service Code	NDC 0002-4815-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 100 MG TABLET [219901]

Facility

$349.93

Service Code	NDC 0002-4815-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.96
Rate for Payer: Aetna of CA Government/Medicare	$209.96
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 150 MG TABLET [219900]

Facility

$349.93

Service Code	NDC 0002-5337-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.96
Rate for Payer: Aetna of CA Government/Medicare	$209.96
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 150 MG TABLET [219900]

Facility

$349.93

Service Code	NDC 0002-5337-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 200 MG TABLET [219899]

Facility

$349.93

Service Code	NDC 0002-6216-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 200 MG TABLET [219899]

Facility

$349.93

Service Code	NDC 0002-6216-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.96
Rate for Payer: Aetna of CA Government/Medicare	$209.96
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 50 MG TABLET [219902]

Facility

$349.93

Service Code	NDC 0002-4483-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABEMACICLIB 50 MG TABLET [219902]

Facility

$349.93

Service Code	NDC 0002-4483-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$192.46
Max. Negotiated Rate	$279.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.96
Rate for Payer: Aetna of CA Government/Medicare	$209.96
Rate for Payer: Cash Price	$192.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.94
Rate for Payer: Health Smart Auto/Commercial	$209.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.96
Rate for Payer: LLUH Dept of Risk Management WC	$192.46
Rate for Payer: Multiplan Commercial	$262.45

ABIRATERONE 250 MG TABLET [109776]

Facility

$119.69

Service Code	NDC 57894-150-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$65.83
Max. Negotiated Rate	$95.75
Rate for Payer: Cash Price	$65.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.75
Rate for Payer: Health Smart Auto/Commercial	$71.81
Rate for Payer: LLUH Dept of Risk Management WC	$65.83
Rate for Payer: Multiplan Commercial	$89.77

ABIRATERONE 250 MG TABLET [109776]

Facility

$119.69

Service Code	NDC 57894-150-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$65.83
Max. Negotiated Rate	$95.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.81
Rate for Payer: Aetna of CA Government/Medicare	$71.81
Rate for Payer: Cash Price	$65.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.75
Rate for Payer: Health Smart Auto/Commercial	$71.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.81
Rate for Payer: LLUH Dept of Risk Management WC	$65.83
Rate for Payer: Multiplan Commercial	$89.77

ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION [106761]

Facility

$634.20

Service Code	HCPCS J0586
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$348.81
Max. Negotiated Rate	$507.36
Rate for Payer: Cash Price	$348.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$507.36
Rate for Payer: Health Smart Auto/Commercial	$380.52
Rate for Payer: LLUH Dept of Risk Management WC	$348.81
Rate for Payer: Multiplan Commercial	$475.65

ABOBOTULINUMTOXINA 300 UNIT INTRAMUSCULAR SOLUTION [106761]

Facility

$634.20

Service Code	HCPCS J0586
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$348.81
Max. Negotiated Rate	$507.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$380.52
Rate for Payer: Aetna of CA Government/Medicare	$380.52
Rate for Payer: Cash Price	$348.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$507.36
Rate for Payer: Health Smart Auto/Commercial	$380.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$380.52
Rate for Payer: LLUH Dept of Risk Management WC	$348.81
Rate for Payer: Multiplan Commercial	$475.65

ACARBOSE 25 MG TABLET [22148]

Facility

$0.36

Service Code	NDC 64380-758-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ACARBOSE 25 MG TABLET [22148]

Facility

$0.36

Service Code	NDC 64380-758-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ACARBOSE 50 MG TABLET [15895]

Facility

$0.61

Service Code	NDC 0054-0141-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

Know your out-of-pocket cost for care.

All Charges