Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CIPROFLOXACIN 0.3 % EYE OINTMENT [23234]

Facility

$93.21

Service Code	NDC 66758-071-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$51.27
Max. Negotiated Rate	$74.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.93
Rate for Payer: Aetna of CA Government/Medicare	$55.93
Rate for Payer: Cash Price	$51.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$74.57
Rate for Payer: Health Smart Auto/Commercial	$55.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.93
Rate for Payer: LLUH Dept of Risk Management WC	$51.27
Rate for Payer: Multiplan Commercial	$69.91

CIPROFLOXACIN 0.3 % EYE OINTMENT [23234]

Facility

$93.21

Service Code	NDC 66758-071-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$51.27
Max. Negotiated Rate	$74.57
Rate for Payer: Cash Price	$51.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$74.57
Rate for Payer: Health Smart Auto/Commercial	$55.93
Rate for Payer: LLUH Dept of Risk Management WC	$51.27
Rate for Payer: Multiplan Commercial	$69.91

CIPROFLOXACIN 250 MG/5 ML ORAL SUSPENSION [22987]

Facility

$1.58

Service Code	NDC 50419-779-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$1.19

CIPROFLOXACIN 250 MG/5 ML ORAL SUSPENSION [22987]

Facility

$1.58

Service Code	NDC 50419-779-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.95
Rate for Payer: Aetna of CA Government/Medicare	$0.95
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$1.19

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.14

Service Code	NDC 55111-126-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.14

Service Code	NDC 55111-126-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.17

Service Code	NDC 0143-9927-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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	$0.13

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.27

Service Code	NDC 65862-076-01
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	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
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	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.17

Service Code	NDC 0143-9927-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
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	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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	$0.13

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.27

Service Code	NDC 65862-076-01
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	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9611]

Facility

$0.04

Service Code	HCPCS J0744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.03

CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [9611]

Facility

$0.04

Service Code	HCPCS J0744
Hospital Charge Code	901700025
Hospital Revenue Code	636
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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 Commercial	$0.03

CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION [22988]

Facility

$1.83

Service Code	NDC 50419-775-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.37

CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION [22988]

Facility

$1.83

Service Code	NDC 50419-775-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.10
Rate for Payer: Aetna of CA Government/Medicare	$1.10
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.37

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.37

Service Code	NDC 59651-867-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.37

Service Code	NDC 59651-867-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.35

Service Code	NDC 0904-7083-61
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

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.21

Service Code	NDC 43547-689-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.35

Service Code	NDC 0904-7083-61
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

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.21

Service Code	NDC 43547-689-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
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	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

CIPROFLOXACIN 750 MG TABLET [25120]

Facility

$0.64

Service Code	NDC 65862-078-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
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	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
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 Commercial	$0.48

CIPROFLOXACIN 750 MG TABLET [25120]

Facility

$0.64

Service Code	NDC 65862-078-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.48

CIPROFLOXACIN 750 MG TABLET [25120]

Facility

$0.60

Service Code	NDC 16571-413-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

CIPROFLOXACIN 750 MG TABLET [25120]

Facility

$0.60

Service Code	NDC 16571-413-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

CIPROFLOXACIN 750 MG TABLET [25120]

Facility

$0.38

Service Code	NDC 55111-128-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

Know your out-of-pocket cost for care.

All Charges