Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.07

Service Code	NDC 67618-200-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.07

Service Code	NDC 67618-200-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

CHLORHEXIDINE (PERIDEX) 0.12% ALCHOHOL-FREE ORAL SYRINGE [4081169]

Facility

$0.02

Service Code	NDC 52376-021-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

CHLORHEXIDINE (PERIDEX) 0.12% ALCHOHOL-FREE ORAL SYRINGE [4081169]

Facility

$0.02

Service Code	NDC 52376-021-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

CHLOROPROCAINE 20 MG/ML (2 %) INJECTION SOLUTION [110537]

Facility

$0.74

Service Code	HCPCS J2401
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

CHLOROPROCAINE 20 MG/ML (2 %) INJECTION SOLUTION [110537]

Facility

$0.74

Service Code	HCPCS J2401
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [1635]

Facility

$1.34

Service Code	HCPCS J2401
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [1635]

Facility

$1.34

Service Code	HCPCS J2401
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

CHLOROQUINE ORAL SUSPENSION COMPOUND 15 MG/ML [4080254]

Facility

$0.16

Service Code	NDC 9994-0802-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

CHLOROQUINE ORAL SUSPENSION COMPOUND 15 MG/ML [4080254]

Facility

$0.16

Service Code	NDC 9994-0802-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION [9525]

Facility

$0.35

Service Code	NDC 65649-311-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION [9525]

Facility

$0.35

Service Code	NDC 65649-311-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]

Facility

$357.24

Service Code	HCPCS J1205
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$196.48
Max. Negotiated Rate	$285.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$214.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$115.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.86
Rate for Payer: Aetna of CA Government/Medicare	$214.34
Rate for Payer: Aetna of CA Government/Medicare	$71.86
Rate for Payer: Aetna of CA Government/Medicare	$20.11
Rate for Payer: Aetna of CA Government/Medicare	$115.20
Rate for Payer: Aetna of CA Government/Medicare	$43.20
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$18.43
Rate for Payer: Cash Price	$196.48
Rate for Payer: Cash Price	$65.87
Rate for Payer: Cash Price	$39.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$285.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$153.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$57.60
Rate for Payer: Health Smart Auto/Commercial	$20.11
Rate for Payer: Health Smart Auto/Commercial	$115.20
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Health Smart Auto/Commercial	$214.34
Rate for Payer: Health Smart Auto/Commercial	$71.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$214.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$115.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$196.48
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$105.60
Rate for Payer: LLUH Dept of Risk Management WC	$65.87
Rate for Payer: LLUH Dept of Risk Management WC	$18.44
Rate for Payer: Multiplan Commercial	$54.00
Rate for Payer: Multiplan Commercial	$89.82
Rate for Payer: Multiplan Commercial	$144.00
Rate for Payer: Multiplan Commercial	$25.14
Rate for Payer: Multiplan Commercial	$267.93

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]

Facility

$357.24

Service Code	HCPCS J1205
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$196.48
Max. Negotiated Rate	$285.79
Rate for Payer: Cash Price	$196.48
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$65.87
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$18.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$285.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$57.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$153.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.81
Rate for Payer: Health Smart Auto/Commercial	$71.86
Rate for Payer: Health Smart Auto/Commercial	$115.20
Rate for Payer: Health Smart Auto/Commercial	$20.11
Rate for Payer: Health Smart Auto/Commercial	$214.34
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$18.44
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$65.87
Rate for Payer: LLUH Dept of Risk Management WC	$196.48
Rate for Payer: LLUH Dept of Risk Management WC	$105.60
Rate for Payer: Multiplan Commercial	$144.00
Rate for Payer: Multiplan Commercial	$267.93
Rate for Payer: Multiplan Commercial	$54.00
Rate for Payer: Multiplan Commercial	$89.82
Rate for Payer: Multiplan Commercial	$25.14

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 68462-861-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 69238-1054-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 68462-861-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 69238-1054-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]

Facility

$19.86

Service Code	HCPCS J3230
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$15.89
Rate for Payer: Cash Price	$10.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.89
Rate for Payer: Health Smart Auto/Commercial	$11.92
Rate for Payer: LLUH Dept of Risk Management WC	$10.92
Rate for Payer: Multiplan Commercial	$14.89

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]

Facility

$19.86

Service Code	HCPCS J3230
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$15.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.92
Rate for Payer: Aetna of CA Government/Medicare	$11.92
Rate for Payer: Cash Price	$10.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.89
Rate for Payer: Health Smart Auto/Commercial	$11.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.92
Rate for Payer: LLUH Dept of Risk Management WC	$10.92
Rate for Payer: Multiplan Commercial	$14.89

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$1.02

Service Code	NDC 68462-862-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$0.51

Service Code	NDC 0527-2962-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$7.11

Service Code	NDC 60687-430-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.27
Rate for Payer: Aetna of CA Government/Medicare	$4.27
Rate for Payer: Cash Price	$3.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.69
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Commercial	$5.33

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$7.11

Service Code	NDC 60687-430-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.27
Rate for Payer: Aetna of CA Government/Medicare	$4.27
Rate for Payer: Cash Price	$3.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.69
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Commercial	$5.33

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$0.51

Service Code	NDC 0527-2962-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

Know your out-of-pocket cost for care.

All Charges