Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML)SUBCUTANEOUS. [4081378]

Facility

$6,480.67

Service Code	CPT J0717
Hospital Charge Code	ERX4081378
Hospital Revenue Code	636
Min. Negotiated Rate	$3,564.37
Max. Negotiated Rate	$5,184.54
Rate for Payer: Cash Price	$2,916.30
Rate for Payer: Cigna of CA HMO/PPO	$5,184.54
Rate for Payer: Health Smart Auto/Commercial	$3,888.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,564.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,860.50

CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML)SUBCUTANEOUS. [4081378]

Facility

$6,480.67

Service Code	CPT J0717
Hospital Charge Code	ERX4081378
Hospital Revenue Code	636
Min. Negotiated Rate	$3,564.37
Max. Negotiated Rate	$4,860.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,888.40
Rate for Payer: Aetna of CA Government/Medicare	$3,888.40
Rate for Payer: Cash Price	$2,916.30
Rate for Payer: Health Smart Auto/Commercial	$3,888.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,888.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,564.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,860.50

CETIRIZINE 1 MG/ML ORAL SOLUTION [70838]

Facility

$0.08

Service Code	NDC 45802-974-26
Hospital Charge Code	NDG70838
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

CETIRIZINE 1 MG/ML ORAL SOLUTION [70838]

Facility

$0.08

Service Code	NDC 45802-974-26
Hospital Charge Code	NDG70838
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION [37989]

Facility

$18.37

Service Code	CPT J9055
Hospital Charge Code	1755711
Hospital Revenue Code	636
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$13.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.02
Rate for Payer: Aetna of CA Government/Medicare	$11.02
Rate for Payer: Cash Price	$8.27
Rate for Payer: Health Smart Auto/Commercial	$11.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.02
Rate for Payer: LLUH Dept of Risk Management WC	$10.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.78

CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION [37989]

Facility

$18.37

Service Code	CPT J9055
Hospital Charge Code	1755711
Hospital Revenue Code	636
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$14.70
Rate for Payer: Cash Price	$8.27
Rate for Payer: Cigna of CA HMO/PPO	$14.70
Rate for Payer: Health Smart Auto/Commercial	$11.02
Rate for Payer: LLUH Dept of Risk Management WC	$10.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.78

CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION [108072]

Facility

$18.37

Service Code	CPT J9055
Hospital Charge Code	1755767
Hospital Revenue Code	636
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$13.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.02
Rate for Payer: Aetna of CA Government/Medicare	$11.02
Rate for Payer: Cash Price	$8.27
Rate for Payer: Health Smart Auto/Commercial	$11.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.02
Rate for Payer: LLUH Dept of Risk Management WC	$10.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.78

CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION [108072]

Facility

$18.37

Service Code	CPT J9055
Hospital Charge Code	1755767
Hospital Revenue Code	636
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$14.70
Rate for Payer: Cash Price	$8.27
Rate for Payer: Cigna of CA HMO/PPO	$14.70
Rate for Payer: Health Smart Auto/Commercial	$11.02
Rate for Payer: LLUH Dept of Risk Management WC	$10.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.78

CEVIMELINE 30 MG CAPSULE [27253]

Facility

$9.77

Service Code	NDC 63395-201-13
Hospital Charge Code	1711933
Hospital Revenue Code	259
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$7.82
Rate for Payer: Cash Price	$4.40
Rate for Payer: Cigna of CA HMO/PPO	$7.82
Rate for Payer: Health Smart Auto/Commercial	$5.86
Rate for Payer: LLUH Dept of Risk Management WC	$5.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.33

CEVIMELINE 30 MG CAPSULE [27253]

Facility

$9.77

Service Code	NDC 63395-201-13
Hospital Charge Code	1711933
Hospital Revenue Code	259
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$7.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.86
Rate for Payer: Aetna of CA Government/Medicare	$5.86
Rate for Payer: Cash Price	$4.40
Rate for Payer: Health Smart Auto/Commercial	$5.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.86
Rate for Payer: LLUH Dept of Risk Management WC	$5.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.33

CHERRY FLAVOR (BULK) ORAL LIQUID [1562]

Facility

$0.04

Service Code	NDC 395266216
Hospital Charge Code	NDG1562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

CHERRY FLAVOR (BULK) ORAL LIQUID [1562]

Facility

$0.04

Service Code	NDC 395266216
Hospital Charge Code	NDG1562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

CHLORAMPHENICOL SODIUM SUCCINATE 1 GRAM INTRAVENOUS SOLUTION [25518]

Facility

$58.38

Service Code	CPT J0720
Hospital Charge Code	ERX25518
Hospital Revenue Code	636
Min. Negotiated Rate	$32.11
Max. Negotiated Rate	$46.70
Rate for Payer: Cash Price	$26.27
Rate for Payer: Cigna of CA HMO/PPO	$46.70
Rate for Payer: Health Smart Auto/Commercial	$35.03
Rate for Payer: LLUH Dept of Risk Management WC	$32.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$43.78

CHLORAMPHENICOL SODIUM SUCCINATE 1 GRAM INTRAVENOUS SOLUTION [25518]

Facility

$58.38

Service Code	CPT J0720
Hospital Charge Code	ERX25518
Hospital Revenue Code	636
Min. Negotiated Rate	$32.11
Max. Negotiated Rate	$43.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.03
Rate for Payer: Aetna of CA Government/Medicare	$35.03
Rate for Payer: Cash Price	$26.27
Rate for Payer: Health Smart Auto/Commercial	$35.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.03
Rate for Payer: LLUH Dept of Risk Management WC	$32.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$43.78

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility

$0.12

Service Code	NDC 0555-0033-05
Hospital Charge Code	1730119
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility

$0.18

Service Code	NDC 0555-0033-02
Hospital Charge Code	1730119
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility

$0.18

Service Code	NDC 0555-0033-02
Hospital Charge Code	1730119
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility

$0.12

Service Code	NDC 0555-0033-05
Hospital Charge Code	1730119
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$0.64

Service Code	NDC 51079-141-01
Hospital Charge Code	1730120
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
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	$0.29
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 Beech St/Commercial/PHCS	$0.48

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$0.20

Service Code	NDC 0555-0159-02
Hospital Charge Code	1730120
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$0.64

Service Code	NDC 51079-141-20
Hospital Charge Code	1730120
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$0.20

Service Code	NDC 0555-0159-02
Hospital Charge Code	1730120
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

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$0.64

Service Code	NDC 51079-141-20
Hospital Charge Code	1730120
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
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	$0.29
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 Beech St/Commercial/PHCS	$0.48

CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]

Facility

$0.64

Service Code	NDC 51079-141-01
Hospital Charge Code	1730120
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

CHLORDIAZEPOXIDE 5 MG CAPSULE [1624]

Facility

$0.77

Service Code	NDC 51079-374-20
Hospital Charge Code	1730118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.58

Know your out-of-pocket cost for care.

All Charges