Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CIPROFLOXACIN 0.3 % EYE DROPS [9610]

Facility

$5.04

Service Code	NDC 69315-308-02
Hospital Charge Code	1740265
Hospital Revenue Code	259
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$3.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.02
Rate for Payer: Aetna of CA Government/Medicare	$3.02
Rate for Payer: Cash Price	$2.27
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

CIPROFLOXACIN 0.3 % EYE DROPS [9610]

Facility

$3.36

Service Code	NDC 69315-308-05
Hospital Charge Code	1740266
Hospital Revenue Code	259
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.69
Rate for Payer: Cash Price	$1.51
Rate for Payer: Cigna of CA HMO/PPO	$2.69
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

CIPROFLOXACIN 0.3 % EYE DROPS [9610]

Facility

$5.04

Service Code	NDC 61314-656-25
Hospital Charge Code	1740265
Hospital Revenue Code	259
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$3.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.02
Rate for Payer: Aetna of CA Government/Medicare	$3.02
Rate for Payer: Cash Price	$2.27
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

CIPROFLOXACIN 0.3 % EYE DROPS [9610]

Facility

$3.36

Service Code	NDC 61314-656-05
Hospital Charge Code	1740266
Hospital Revenue Code	259
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.02
Rate for Payer: Aetna of CA Government/Medicare	$2.02
Rate for Payer: Cash Price	$1.51
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

CIPROFLOXACIN 0.3 % EYE DROPS [9610]

Facility

$3.36

Service Code	NDC 61314-656-05
Hospital Charge Code	1740266
Hospital Revenue Code	259
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.69
Rate for Payer: Cash Price	$1.51
Rate for Payer: Cigna of CA HMO/PPO	$2.69
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

CIPROFLOXACIN 0.3 % EYE DROPS [9610]

Facility

$5.04

Service Code	NDC 69315-308-02
Hospital Charge Code	1740265
Hospital Revenue Code	259
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$4.03
Rate for Payer: Cash Price	$2.27
Rate for Payer: Cigna of CA HMO/PPO	$4.03
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

CIPROFLOXACIN 0.3 % EYE OINTMENT [23234]

Facility

$77.17

Service Code	NDC 0078-0841-01
Hospital Charge Code	1740324
Hospital Revenue Code	259
Min. Negotiated Rate	$42.44
Max. Negotiated Rate	$61.74
Rate for Payer: Cash Price	$34.73
Rate for Payer: Cigna of CA HMO/PPO	$61.74
Rate for Payer: Health Smart Auto/Commercial	$46.30
Rate for Payer: LLUH Dept of Risk Management WC	$42.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$57.88

CIPROFLOXACIN 0.3 % EYE OINTMENT [23234]

Facility

$77.17

Service Code	NDC 0078-0841-01
Hospital Charge Code	1740324
Hospital Revenue Code	259
Min. Negotiated Rate	$42.44
Max. Negotiated Rate	$57.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$46.30
Rate for Payer: Aetna of CA Government/Medicare	$46.30
Rate for Payer: Cash Price	$34.73
Rate for Payer: Health Smart Auto/Commercial	$46.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$46.30
Rate for Payer: LLUH Dept of Risk Management WC	$42.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$57.88

CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108130]

Facility

$0.04

Service Code	CPT J0744
Hospital Charge Code	1753414
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108130]

Facility

$0.03

Service Code	CPT J0744
Hospital Charge Code	1753414
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

CIPROFLOXACIN 250 MG/5 ML ORAL SUSPENSION [22987]

Facility

$1.59

Service Code	NDC 50419-779-01
Hospital Charge Code	1715974
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.27
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cigna of CA HMO/PPO	$1.27
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.19

CIPROFLOXACIN 250 MG/5 ML ORAL SUSPENSION [22987]

Facility

$1.59

Service Code	NDC 50419-779-01
Hospital Charge Code	1715974
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.19
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	$0.72
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 Beech St/Commercial/PHCS	$1.19

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.17

Service Code	NDC 0143-9927-01
Hospital Charge Code	1711145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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	$0.08
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	$0.13

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.14

Service Code	NDC 55111-126-01
Hospital Charge Code	1711145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.14

Service Code	NDC 55111-126-01
Hospital Charge Code	1711145
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	$0.06
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 Beech St/Commercial/PHCS	$0.11

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.27

Service Code	NDC 65862-076-01
Hospital Charge Code	1711145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.20
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	$0.12
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 Beech St/Commercial/PHCS	$0.20

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.17

Service Code	NDC 0143-9927-01
Hospital Charge Code	1711145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.13

CIPROFLOXACIN 250 MG TABLET [25118]

Facility

$0.27

Service Code	NDC 65862-076-01
Hospital Charge Code	1711145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

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

Facility

$0.04

Service Code	CPT J0744
Hospital Charge Code	1753415
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

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

Facility

$0.02

Service Code	CPT J0744
Hospital Charge Code	1753415
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION [22988]

Facility

$1.83

Service Code	NDC 50419-775-01
Hospital Charge Code	1715975
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.37
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	$0.82
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 Beech St/Commercial/PHCS	$1.37

CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION [22988]

Facility

$1.83

Service Code	NDC 50419-775-01
Hospital Charge Code	1715975
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$0.82
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.37

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.23

Service Code	NDC 55111-127-01
Hospital Charge Code	1711159
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.35

Service Code	NDC 0904-7083-61
Hospital Charge Code	1711159
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

CIPROFLOXACIN 500 MG TABLET [25119]

Facility

$0.35

Service Code	NDC 0904-7083-61
Hospital Charge Code	1711159
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

Know your out-of-pocket cost for care.

All Charges