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 3172256224
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	$0.28
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 Foundation Hospitals Commercial/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 3172256224
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
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 3172255760
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	$1.35
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 Foundation Hospitals Commercial/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 6808402111
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$8.47
Rate for Payer: Cash Price	$4.77
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 6808402111
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	$4.77
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 Foundation Hospitals Commercial/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 3172255760
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
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

$160.57

Service Code	NDC 4970223113
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$128.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.34
Rate for Payer: Aetna of CA Government/Medicare	$96.34
Rate for Payer: Cash Price	$72.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$128.46
Rate for Payer: Health Smart Auto/Commercial	$96.34
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$96.34
Rate for Payer: LLUH Dept of Risk Management WC	$88.31
Rate for Payer: Multiplan Commercial	$120.43

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

Facility

$160.57

Service Code	NDC 4970223113
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$128.46
Rate for Payer: Cash Price	$72.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$128.46
Rate for Payer: Health Smart Auto/Commercial	$96.34
Rate for Payer: LLUH Dept of Risk Management WC	$88.31
Rate for Payer: Multiplan Commercial	$120.43

ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET [39301]

Facility

$4.00

Service Code	NDC 6909736202
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
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 6909736202
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	$1.80
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION [70287]

Facility

$1,925.10

Service Code	HCPCS J0129
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1,058.81
Max. Negotiated Rate	$1,540.08
Rate for Payer: Cash Price	$866.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,540.08
Rate for Payer: Health Smart Auto/Commercial	$1,155.06
Rate for Payer: LLUH Dept of Risk Management WC	$1,058.81
Rate for Payer: Multiplan Commercial	$1,443.83

ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION [70287]

Facility

$1,925.10

Service Code	HCPCS J0129
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.72
Max. Negotiated Rate	$1,540.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,155.06
Rate for Payer: Aetna of CA Government/Medicare	$1,155.06
Rate for Payer: Cash Price	$866.30
Rate for Payer: Cash Price	$866.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,540.08
Rate for Payer: Health Smart Auto/Commercial	$1,155.06
Rate for Payer: Intervalley Health Plan Commercial	$44.72
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1,155.06
Rate for Payer: LLUH Dept of Risk Management WC	$1,058.81
Rate for Payer: Multiplan Commercial	$1,443.83

ABEMACICLIB 100 MG TABLET [219901]

Facility

$370.93

Service Code	NDC 0002481554
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$222.56
Rate for Payer: Aetna of CA Government/Medicare	$222.56
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 100 MG TABLET [219901]

Facility

$370.93

Service Code	NDC 0002481554
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 150 MG TABLET [219900]

Facility

$370.93

Service Code	NDC 0002533754
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 150 MG TABLET [219900]

Facility

$370.93

Service Code	NDC 0002533754
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$222.56
Rate for Payer: Aetna of CA Government/Medicare	$222.56
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 200 MG TABLET [219899]

Facility

$370.93

Service Code	NDC 0002621654
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 200 MG TABLET [219899]

Facility

$370.93

Service Code	NDC 0002621654
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$222.56
Rate for Payer: Aetna of CA Government/Medicare	$222.56
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 50 MG TABLET [219902]

Facility

$370.93

Service Code	NDC 0002448354
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABEMACICLIB 50 MG TABLET [219902]

Facility

$370.93

Service Code	NDC 0002448354
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$204.01
Max. Negotiated Rate	$296.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$222.56
Rate for Payer: Aetna of CA Government/Medicare	$222.56
Rate for Payer: Cash Price	$166.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$296.74
Rate for Payer: Health Smart Auto/Commercial	$222.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$222.56
Rate for Payer: LLUH Dept of Risk Management WC	$204.01
Rate for Payer: Multiplan Commercial	$278.20

ABIRATERONE 250 MG TABLET [109776]

Facility

$125.67

Service Code	NDC 5789415012
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$100.54
Rate for Payer: Cash Price	$56.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.54
Rate for Payer: Health Smart Auto/Commercial	$75.40
Rate for Payer: LLUH Dept of Risk Management WC	$69.12
Rate for Payer: Multiplan Commercial	$94.25

ABIRATERONE 250 MG TABLET [109776]

Facility

$125.67

Service Code	NDC 5789415012
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$100.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.40
Rate for Payer: Aetna of CA Government/Medicare	$75.40
Rate for Payer: Cash Price	$56.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.54
Rate for Payer: Health Smart Auto/Commercial	$75.40
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$75.40
Rate for Payer: LLUH Dept of Risk Management WC	$69.12
Rate for Payer: Multiplan Commercial	$94.25

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	$285.39
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	$8.90
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	$285.39
Rate for Payer: Cash Price	$285.39
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: Intervalley Health Plan Commercial	$8.90
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$380.52
Rate for Payer: LLUH Dept of Risk Management WC	$348.81
Rate for Payer: Multiplan Commercial	$475.65

ABOBOTULINUMTOXINA 500 UNIT INTRAMUSCULAR SOLUTION [99465]

Facility

$1,056.60

Service Code	HCPCS J0586
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$845.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$633.96
Rate for Payer: Aetna of CA Government/Medicare	$633.96
Rate for Payer: Cash Price	$475.47
Rate for Payer: Cash Price	$475.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$845.28
Rate for Payer: Health Smart Auto/Commercial	$633.96
Rate for Payer: Intervalley Health Plan Commercial	$8.90
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$633.96
Rate for Payer: LLUH Dept of Risk Management WC	$581.13
Rate for Payer: Multiplan Commercial	$792.45

Know your out-of-pocket cost for care.

All Charges