Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Commercial	$5.33

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: 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: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

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

$1.02

Service Code	NDC 69238-1056-1
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

$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

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.70

Service Code	NDC 60687-317-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.62
Rate for Payer: Aetna of CA Government/Medicare	$1.62
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.02

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.70

Service Code	NDC 60687-317-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.16
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.02

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.02

Service Code	NDC 0904582360
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

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.28

Service Code	NDC 5026886315
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.22

Service Code	NDC 6809411461
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.17

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.02

Service Code	NDC 0904582360
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

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.28

Service Code	NDC 5026886315
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$2.20

Service Code	NDC 6809411459
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.32
Rate for Payer: Aetna of CA Government/Medicare	$1.32
Rate for Payer: Cash Price	$1.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.76
Rate for Payer: Health Smart Auto/Commercial	$1.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.21
Rate for Payer: Multiplan Commercial	$1.65

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.22

Service Code	NDC 6809411461
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
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	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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 Commercial	$0.17

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.28

Service Code	NDC 5026886311
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$2.20

Service Code	NDC 6809411459
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.76
Rate for Payer: Cash Price	$1.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.76
Rate for Payer: Health Smart Auto/Commercial	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.21
Rate for Payer: Multiplan Commercial	$1.65

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [112022]

Facility

$0.28

Service Code	NDC 5026886311
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

Know your out-of-pocket cost for care.

All Charges