Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CITRULLINE 600 MG CAPSULE [13319]

Facility

$76.00

Service Code	NDC 53335-00689
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$41.80
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.60
Rate for Payer: Aetna of CA Government/Medicare	$45.60
Rate for Payer: Cash Price	$41.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.80
Rate for Payer: Health Smart Auto/Commercial	$45.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.60
Rate for Payer: LLUH Dept of Risk Management WC	$41.80
Rate for Payer: Multiplan Commercial	$57.00

CITRULLINE POWDER. [40819153]

Facility

$6.47

Service Code	NDC 6299127531
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$5.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.88
Rate for Payer: Aetna of CA Government/Medicare	$3.88
Rate for Payer: Cash Price	$3.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.18
Rate for Payer: Health Smart Auto/Commercial	$3.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.88
Rate for Payer: LLUH Dept of Risk Management WC	$3.56
Rate for Payer: Multiplan Commercial	$4.85

CITRULLINE POWDER. [40819153]

Facility

$6.47

Service Code	NDC 6299127531
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$5.18
Rate for Payer: Cash Price	$3.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.18
Rate for Payer: Health Smart Auto/Commercial	$3.88
Rate for Payer: LLUH Dept of Risk Management WC	$3.56
Rate for Payer: Multiplan Commercial	$4.85

CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION [9615]

Facility

$52.20

Service Code	HCPCS J9065
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$41.76
Rate for Payer: Cash Price	$28.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$41.76
Rate for Payer: Health Smart Auto/Commercial	$31.32
Rate for Payer: LLUH Dept of Risk Management WC	$28.71
Rate for Payer: Multiplan Commercial	$39.15

CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION [9615]

Facility

$52.20

Service Code	HCPCS J9065
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$41.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.32
Rate for Payer: Aetna of CA Government/Medicare	$31.32
Rate for Payer: Cash Price	$28.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$41.76
Rate for Payer: Health Smart Auto/Commercial	$31.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.32
Rate for Payer: LLUH Dept of Risk Management WC	$28.71
Rate for Payer: Multiplan Commercial	$39.15

CLARITHROMYCIN 125 MG/5 ML ORAL SUSPENSION [12885]

Facility

$1.44

Service Code	NDC 0781-6022-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.08

CLARITHROMYCIN 125 MG/5 ML ORAL SUSPENSION [12885]

Facility

$1.55

Service Code	NDC 0781-6022-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.93
Rate for Payer: Aetna of CA Government/Medicare	$0.93
Rate for Payer: Cash Price	$0.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.24
Rate for Payer: Health Smart Auto/Commercial	$0.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.93
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Commercial	$1.16

CLARITHROMYCIN 125 MG/5 ML ORAL SUSPENSION [12885]

Facility

$1.55

Service Code	NDC 0781-6022-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.24
Rate for Payer: Cash Price	$0.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.24
Rate for Payer: Health Smart Auto/Commercial	$0.93
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Commercial	$1.16

CLARITHROMYCIN 125 MG/5 ML ORAL SUSPENSION [12885]

Facility

$1.44

Service Code	NDC 0781-6022-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.08

CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION [12886]

Facility

$2.26

Service Code	NDC 0781-6023-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.81
Rate for Payer: Cash Price	$1.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.81
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: Multiplan Commercial	$1.70

CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION [12886]

Facility

$2.26

Service Code	NDC 0781-6023-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Cash Price	$1.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.81
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: Multiplan Commercial	$1.70

CLARITHROMYCIN 250 MG TABLET [9616]

Facility

$1.17

Service Code	NDC 0781-1961-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.88

CLARITHROMYCIN 250 MG TABLET [9616]

Facility

$1.17

Service Code	NDC 0781-1961-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.88

CLARITHROMYCIN 500 MG TABLET [9617]

Facility

$1.17

Service Code	NDC 0781-1962-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.88

CLARITHROMYCIN 500 MG TABLET [9617]

Facility

$1.17

Service Code	NDC 0781-1962-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.88

CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION [93936]

Facility

$2.12

Service Code	HCPCS C9248
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.59

CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION [93936]

Facility

$2.12

Service Code	HCPCS C9248
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.59

CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [1743]

Facility

$0.72

Service Code	HCPCS J0736
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.97
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.91
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: Multiplan Commercial	$0.54
Rate for Payer: Multiplan Commercial	$0.64
Rate for Payer: Multiplan Commercial	$0.95

CLINDAMYCIN 150 MG/ML INJECTION SOLUTION [1743]

Facility

$1.27

Service Code	HCPCS J0736
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.51
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.64
Rate for Payer: Multiplan Commercial	$0.95
Rate for Payer: Multiplan Commercial	$0.91
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: Multiplan Commercial	$0.54

CLINDAMYCIN 1 % LOTION [19711]

Facility

$2.31

Service Code	NDC 0168-0203-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.39
Rate for Payer: Aetna of CA Government/Medicare	$1.39
Rate for Payer: Cash Price	$1.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.85
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.27
Rate for Payer: Multiplan Commercial	$1.73

CLINDAMYCIN 1 % LOTION [19711]

Facility

$2.31

Service Code	NDC 0168-0203-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$1.85
Rate for Payer: Cash Price	$1.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.85
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.27
Rate for Payer: Multiplan Commercial	$1.73

CLINDAMYCIN 1 % TOPICAL GEL [9623]

Facility

$3.32

Service Code	NDC 0168-0202-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.99
Rate for Payer: Aetna of CA Government/Medicare	$1.99
Rate for Payer: Cash Price	$1.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.49

CLINDAMYCIN 1 % TOPICAL GEL [9623]

Facility

$3.32

Service Code	NDC 0168-0202-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.49

CLINDAMYCIN 1 % TOPICAL GEL [9623]

Facility

$2.76

Service Code	NDC 59762-3743-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.66
Rate for Payer: Aetna of CA Government/Medicare	$1.66
Rate for Payer: Cash Price	$1.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.21
Rate for Payer: Health Smart Auto/Commercial	$1.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$2.07

CLINDAMYCIN 1 % TOPICAL GEL [9623]

Facility

$2.76

Service Code	NDC 59762-3743-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.21
Rate for Payer: Cash Price	$1.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.21
Rate for Payer: Health Smart Auto/Commercial	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$2.07

Know your out-of-pocket cost for care.

All Charges