Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$5.82

Service Code	NDC 0713-0317-88
Hospital Charge Code	1743748
Hospital Revenue Code	259
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$4.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.49
Rate for Payer: Aetna of CA Government/Medicare	$3.49
Rate for Payer: Cash Price	$2.62
Rate for Payer: Health Smart Auto/Commercial	$3.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.49
Rate for Payer: LLUH Dept of Risk Management WC	$3.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.36

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$6.76

Service Code	NDC 50383-419-06
Hospital Charge Code	1743748
Hospital Revenue Code	259
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$5.41
Rate for Payer: Cash Price	$3.04
Rate for Payer: Cigna of CA HMO/PPO	$5.41
Rate for Payer: Health Smart Auto/Commercial	$4.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.07

CIDOFOVIR 10 MG/ML TOPICAL [4082503]

Facility

$24.48

Service Code	NDC 9994-0825-03
Hospital Revenue Code	636
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$18.36
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	$11.02
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 Beech St/Commercial/PHCS	$18.36

CIDOFOVIR 10 MG/ML TOPICAL [4082503]

Facility

$24.48

Service Code	NDC 9994-0825-03
Hospital Revenue Code	636
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$19.58
Rate for Payer: Cash Price	$11.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$18.36

CIDOFOVIR 15 MG/ML TOPICAL [4081161]

Facility

$36.54

Service Code	NDC 99994-811-61
Hospital Charge Code	NDC4081161
Hospital Revenue Code	636
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$29.23
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$29.23
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 15 MG/ML TOPICAL [4081161]

Facility

$36.54

Service Code	NDC 99994-811-61
Hospital Charge Code	NDC4081161
Hospital Revenue Code	636
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$27.40
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	$16.44
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	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 1 MG/ML TOPICAL [4081092]

Facility

$36.54

Service Code	NDC 99994-811-92
Hospital Charge Code	NDC4081092
Hospital Revenue Code	636
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$27.40
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	$16.44
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	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 1 MG/ML TOPICAL [4081092]

Facility

$36.54

Service Code	NDC 99994-811-92
Hospital Charge Code	NDC4081092
Hospital Revenue Code	636
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$29.23
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$29.23
Rate for Payer: LLUH Dept of Risk Management WC	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 3 MG/ML TOPICAL [4081091]

Facility

$36.54

Service Code	NDC 99994-811-91
Hospital Revenue Code	636
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$29.23
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$29.23
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 3 MG/ML TOPICAL [4081091]

Facility

$36.54

Service Code	NDC 99994-811-91
Hospital Revenue Code	636
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$27.40
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	$16.44
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	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 5 MG/ML TOPICAL [4081159]

Facility

$36.54

Service Code	NDC 99994-811-59
Hospital Charge Code	NDC4081159
Hospital Revenue Code	259
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$27.40
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	$16.44
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	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 5 MG/ML TOPICAL [4081159]

Facility

$36.54

Service Code	NDC 99994-811-59
Hospital Charge Code	NDC4081159
Hospital Revenue Code	259
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$29.23
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$29.23
Rate for Payer: Health Smart Auto/Commercial	$21.92
Rate for Payer: LLUH Dept of Risk Management WC	$20.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.40

CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]

Facility

$177.60

Service Code	CPT J0740
Hospital Charge Code	1757059
Hospital Revenue Code	636
Min. Negotiated Rate	$97.68
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.56
Rate for Payer: Aetna of CA Government/Medicare	$106.56
Rate for Payer: Cash Price	$79.92
Rate for Payer: Health Smart Auto/Commercial	$106.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.56
Rate for Payer: LLUH Dept of Risk Management WC	$97.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.20

CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]

Facility

$177.60

Service Code	CPT J0740
Hospital Charge Code	1757059
Hospital Revenue Code	636
Min. Negotiated Rate	$97.68
Max. Negotiated Rate	$142.08
Rate for Payer: Cash Price	$79.92
Rate for Payer: Cigna of CA HMO/PPO	$142.08
Rate for Payer: Health Smart Auto/Commercial	$106.56
Rate for Payer: LLUH Dept of Risk Management WC	$97.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.20

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.43

Service Code	NDC 0054-0044-29
Hospital Charge Code	1710971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.72

Service Code	NDC 0185-0223-60
Hospital Charge Code	1710971
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

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.44

Service Code	NDC 0093-2064-06
Hospital Charge Code	1710971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.33

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.72

Service Code	NDC 0185-0223-60
Hospital Charge Code	1710971
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

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.43

Service Code	NDC 0054-0044-21
Hospital Charge Code	1710971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.43

Service Code	NDC 0054-0044-21
Hospital Charge Code	1710971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.44

Service Code	NDC 0093-2064-06
Hospital Charge Code	1710971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.33

CILOSTAZOL 100 MG TABLET [24474]

Facility

$0.43

Service Code	NDC 0054-0044-29
Hospital Charge Code	1710971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

CINACALCET 15 MG PARTIAL TABLET [40820825]

Facility

$0.60

Service Code	NDC 16729-440-10
Hospital Charge Code	ERX40820825
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
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	$0.27
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 Beech St/Commercial/PHCS	$0.45

CINACALCET 15 MG PARTIAL TABLET [40820825]

Facility

$0.60

Service Code	NDC 16729-440-10
Hospital Charge Code	ERX40820825
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.45

CINACALCET 15 MG PARTIAL TABLET [40820825]

Facility

$0.60

Service Code	NDC 69097-410-02
Hospital Charge Code	ERX40820825
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.45

Know your out-of-pocket cost for care.

All Charges