Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CHONDROITIN-SOD HYALURON 3 %-4 %(0.35 ML)1 %(0.4 ML)INTRAOCULAR SYRING [28916]

Facility

$416.85

Service Code	NDC 8065183135
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$229.27
Max. Negotiated Rate	$333.48
Rate for Payer: Cash Price	$229.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$333.48
Rate for Payer: Health Smart Auto/Commercial	$250.11
Rate for Payer: LLUH Dept of Risk Management WC	$229.27
Rate for Payer: Multiplan Commercial	$312.64

CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE [28923]

Facility

$475.85

Service Code	NDC 8065183905
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$261.72
Max. Negotiated Rate	$380.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$285.51
Rate for Payer: Aetna of CA Government/Medicare	$285.51
Rate for Payer: Cash Price	$261.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$380.68
Rate for Payer: Health Smart Auto/Commercial	$285.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$285.51
Rate for Payer: LLUH Dept of Risk Management WC	$261.72
Rate for Payer: Multiplan Commercial	$356.89

CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE [28923]

Facility

$475.85

Service Code	NDC 8065183905
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$261.72
Max. Negotiated Rate	$380.68
Rate for Payer: Cash Price	$261.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$380.68
Rate for Payer: Health Smart Auto/Commercial	$285.51
Rate for Payer: LLUH Dept of Risk Management WC	$261.72
Rate for Payer: Multiplan Commercial	$356.89

CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]

Facility

$2.38

Service Code	NDC 0409-4093-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Commercial	$1.78

CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]

Facility

$2.38

Service Code	NDC 0409-4093-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.43
Rate for Payer: Aetna of CA Government/Medicare	$1.43
Rate for Payer: Cash Price	$1.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Commercial	$1.78

C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]

Facility

$389.28

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$214.10
Max. Negotiated Rate	$311.42
Rate for Payer: Cash Price	$214.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$311.42
Rate for Payer: Health Smart Auto/Commercial	$233.57
Rate for Payer: LLUH Dept of Risk Management WC	$214.10
Rate for Payer: Multiplan Commercial	$291.96

C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]

Facility

$389.28

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$214.10
Max. Negotiated Rate	$311.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$233.57
Rate for Payer: Aetna of CA Government/Medicare	$233.57
Rate for Payer: Cash Price	$214.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$311.42
Rate for Payer: Health Smart Auto/Commercial	$233.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$233.57
Rate for Payer: LLUH Dept of Risk Management WC	$214.10
Rate for Payer: Multiplan Commercial	$291.96

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.08

Service Code	NDC 45802-138-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.08

Service Code	NDC 45802-138-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$4.36

Service Code	NDC 45802-141-67
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.62
Rate for Payer: Aetna of CA Government/Medicare	$2.62
Rate for Payer: Cash Price	$2.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.49
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$3.27

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$4.36

Service Code	NDC 45802-141-67
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.49
Rate for Payer: Cash Price	$2.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.49
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$3.27

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$3.10

Service Code	NDC 21922-053-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$2.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.86
Rate for Payer: Aetna of CA Government/Medicare	$1.86
Rate for Payer: Cash Price	$1.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.48
Rate for Payer: Health Smart Auto/Commercial	$1.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.86
Rate for Payer: LLUH Dept of Risk Management WC	$1.71
Rate for Payer: Multiplan Commercial	$2.33

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$3.10

Service Code	NDC 21922-053-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$2.48
Rate for Payer: Cash Price	$1.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.48
Rate for Payer: Health Smart Auto/Commercial	$1.86
Rate for Payer: LLUH Dept of Risk Management WC	$1.71
Rate for Payer: Multiplan Commercial	$2.33

CIDOFOVIR 10 MG/ML TOPICAL [4082503]

Facility

$24.48

Service Code	NDC 9994-0825-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$19.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.69
Rate for Payer: Aetna of CA Government/Medicare	$14.69
Rate for Payer: Cash Price	$13.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.58
Rate for Payer: Health Smart Auto/Commercial	$14.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.69
Rate for Payer: LLUH Dept of Risk Management WC	$13.46
Rate for Payer: Multiplan Commercial	$18.36

CIDOFOVIR 10 MG/ML TOPICAL [4082503]

Facility

$24.48

Service Code	NDC 9994-0825-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$19.58
Rate for Payer: Cash Price	$13.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.58
Rate for Payer: Health Smart Auto/Commercial	$14.69
Rate for Payer: LLUH Dept of Risk Management WC	$13.46
Rate for Payer: Multiplan Commercial	$18.36

CIDOFOVIR 15 MG/ML TOPICAL [4081161]

Facility

$36.53

Service Code	NDC 99994-811-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.92
Rate for Payer: Aetna of CA Government/Medicare	$21.92
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 15 MG/ML TOPICAL [4081161]

Facility

$36.53

Service Code	NDC 99994-811-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 1 MG/ML TOPICAL [4081092]

Facility

$36.53

Service Code	NDC 99994-811-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 1 MG/ML TOPICAL [4081092]

Facility

$36.53

Service Code	NDC 99994-811-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.92
Rate for Payer: Aetna of CA Government/Medicare	$21.92
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 3 MG/ML TOPICAL [4081091]

Facility

$36.53

Service Code	NDC 99994-811-91
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 3 MG/ML TOPICAL [4081091]

Facility

$36.53

Service Code	NDC 99994-811-91
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.92
Rate for Payer: Aetna of CA Government/Medicare	$21.92
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 5 MG/ML TOPICAL [4081159]

Facility

$36.53

Service Code	NDC 99994-811-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.92
Rate for Payer: Aetna of CA Government/Medicare	$21.92
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 5 MG/ML TOPICAL [4081159]

Facility

$36.53

Service Code	NDC 99994-811-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.09
Max. Negotiated Rate	$29.22
Rate for Payer: Cash Price	$20.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.22
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.09
Rate for Payer: Multiplan Commercial	$27.40

CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]

Facility

$177.60

Service Code	HCPCS J0740
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$97.68
Max. Negotiated Rate	$142.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$142.37
Rate for Payer: Aetna of CA Government/Medicare	$142.37
Rate for Payer: Aetna of CA Government/Medicare	$106.56
Rate for Payer: Cash Price	$130.51
Rate for Payer: Cash Price	$97.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$189.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$142.08
Rate for Payer: Health Smart Auto/Commercial	$106.56
Rate for Payer: Health Smart Auto/Commercial	$142.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$142.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.56
Rate for Payer: LLUH Dept of Risk Management WC	$130.51
Rate for Payer: LLUH Dept of Risk Management WC	$97.68
Rate for Payer: Multiplan Commercial	$177.97
Rate for Payer: Multiplan Commercial	$133.20

CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]

Facility

$177.60

Service Code	HCPCS J0740
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$97.68
Max. Negotiated Rate	$142.08
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$130.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$142.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$189.83
Rate for Payer: Health Smart Auto/Commercial	$106.56
Rate for Payer: Health Smart Auto/Commercial	$142.37
Rate for Payer: LLUH Dept of Risk Management WC	$130.51
Rate for Payer: LLUH Dept of Risk Management WC	$97.68
Rate for Payer: Multiplan Commercial	$133.20
Rate for Payer: Multiplan Commercial	$177.97

Know your out-of-pocket cost for care.

All Charges