Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.05

Service Code	NDC 46122-137-34
Hospital Charge Code	1719215
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.03

Service Code	NDC 0234-0575-08
Hospital Charge Code	1719215
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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	$0.02

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.06

Service Code	NDC 67618-200-04
Hospital Charge Code	NDG28188B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
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	$0.03
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	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.06

Service Code	NDC 67618-200-04
Hospital Charge Code	NDG28188B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.05

Service Code	NDC 46122-137-34
Hospital Charge Code	1719215
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [28188]

Facility

$0.04

Service Code	NDC 0116-1061-04
Hospital Charge Code	NDG28188B
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

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

Facility

$0.02

Service Code	NDC 52376-021-02
Hospital Charge Code	NDG4081169
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: 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 Beech St/Commercial/PHCS	$0.02

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

Facility

$0.02

Service Code	NDC 52376-021-02
Hospital Charge Code	NDG4081169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.02

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

Facility

$0.74

Service Code	CPT J2401
Hospital Charge Code	1721143
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.56
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	$0.33
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 Beech St/Commercial/PHCS	$0.56

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

Facility

$0.74

Service Code	CPT J2401
Hospital Charge Code	1721143
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.56

CHLOROPROCAINE (PF) 10 MG/ML (1 %) INTRATHECAL SOLUTION [222772]

Facility

$3.69

Service Code	CPT J2402
Hospital Charge Code	NDG222772
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.95
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cigna of CA HMO/PPO	$2.95
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77

CHLOROPROCAINE (PF) 10 MG/ML (1 %) INTRATHECAL SOLUTION [222772]

Facility

$3.69

Service Code	CPT J2402
Hospital Charge Code	NDG222772
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.21
Rate for Payer: Aetna of CA Government/Medicare	$2.21
Rate for Payer: Cash Price	$1.66
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77

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

Facility

$1.34

Service Code	CPT J2401
Hospital Charge Code	1721145
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.00

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

Facility

$1.34

Service Code	CPT J2401
Hospital Charge Code	1721145
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.00
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	$0.60
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 Beech St/Commercial/PHCS	$1.00

CHLOROQUINE ORAL SUSPENSION COMPOUND 15 MG/ML [4080254]

Facility

$0.16

Service Code	NDC 9994-0802-54
Hospital Charge Code	1715014
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
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	$0.07
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 Beech St/Commercial/PHCS	$0.12

CHLOROQUINE ORAL SUSPENSION COMPOUND 15 MG/ML [4080254]

Facility

$0.16

Service Code	NDC 9994-0802-54
Hospital Charge Code	1715014
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.12

CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION [9525]

Facility

$0.35

Service Code	NDC 65649-311-12
Hospital Charge Code	1715531
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
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	$0.16
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 Beech St/Commercial/PHCS	$0.26

CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION [9525]

Facility

$0.35

Service Code	NDC 65649-311-12
Hospital Charge Code	1715531
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.26

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]

Facility

$119.76

Service Code	CPT J1205
Hospital Charge Code	1720125
Hospital Revenue Code	636
Min. Negotiated Rate	$65.87
Max. Negotiated Rate	$95.81
Rate for Payer: Cash Price	$53.89
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$160.76
Rate for Payer: Cash Price	$26.29
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna of CA HMO/PPO	$57.60
Rate for Payer: Cigna of CA HMO/PPO	$95.81
Rate for Payer: Cigna of CA HMO/PPO	$285.79
Rate for Payer: Cigna of CA HMO/PPO	$153.60
Rate for Payer: Cigna of CA HMO/PPO	$46.74
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Health Smart Auto/Commercial	$115.20
Rate for Payer: Health Smart Auto/Commercial	$71.86
Rate for Payer: Health Smart Auto/Commercial	$214.34
Rate for Payer: Health Smart Auto/Commercial	$35.06
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	$32.14
Rate for Payer: LLUH Dept of Risk Management WC	$105.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$267.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$43.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$144.00

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]

Facility

$119.76

Service Code	CPT J1205
Hospital Charge Code	1720125
Hospital Revenue Code	636
Min. Negotiated Rate	$65.87
Max. Negotiated Rate	$89.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$115.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$214.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.06
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	$43.20
Rate for Payer: Aetna of CA Government/Medicare	$35.06
Rate for Payer: Aetna of CA Government/Medicare	$115.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$160.76
Rate for Payer: Cash Price	$26.29
Rate for Payer: Cash Price	$53.89
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Smart Auto/Commercial	$35.06
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Health Smart Auto/Commercial	$115.20
Rate for Payer: Health Smart Auto/Commercial	$71.86
Rate for Payer: Health Smart Auto/Commercial	$214.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.06
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.86
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: LLUH Dept of Risk Management WC	$65.87
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$32.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$43.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$267.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$144.00

CHLORPROMAZINE 100 MG TABLET [1654]

Facility

$14.98

Service Code	NDC 0904-6895-61
Hospital Charge Code	1710686
Hospital Revenue Code	259
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$11.98
Rate for Payer: Cash Price	$6.74
Rate for Payer: Cigna of CA HMO/PPO	$11.98
Rate for Payer: Health Smart Auto/Commercial	$8.99
Rate for Payer: LLUH Dept of Risk Management WC	$8.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.24

CHLORPROMAZINE 100 MG TABLET [1654]

Facility

$14.98

Service Code	NDC 0904-6895-61
Hospital Charge Code	1710686
Hospital Revenue Code	259
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$11.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.99
Rate for Payer: Aetna of CA Government/Medicare	$8.99
Rate for Payer: Cash Price	$6.74
Rate for Payer: Health Smart Auto/Commercial	$8.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.99
Rate for Payer: LLUH Dept of Risk Management WC	$8.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.24

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 68462-861-01
Hospital Charge Code	1711161
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.54

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 69238-1054-1
Hospital Charge Code	1711161
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.54

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 69238-1054-1
Hospital Charge Code	1711161
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
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	$0.32
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 Beech St/Commercial/PHCS	$0.54

Know your out-of-pocket cost for care.

All Charges