Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CLOBAZAM 10 MG TABLET [153175]

Facility

$0.37

Service Code	NDC 42571-315-01
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

CLOBAZAM 10 MG TABLET [153175]

Facility

$3.12

Service Code	NDC 60687-423-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

CLOBAZAM 10 MG TABLET [153175]

Facility

$0.88

Service Code	NDC 0832-0580-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66

CLOBAZAM 10 MG TABLET [153175]

Facility

$0.88

Service Code	NDC 0832-0580-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66

CLOBAZAM 20 MG TABLET [153176]

Facility

$75.14

Service Code	NDC 67386-315-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$41.33
Max. Negotiated Rate	$60.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.08
Rate for Payer: Aetna of CA Government/Medicare	$45.08
Rate for Payer: Cash Price	$41.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.11
Rate for Payer: Health Smart Auto/Commercial	$45.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.08
Rate for Payer: LLUH Dept of Risk Management WC	$41.33
Rate for Payer: Multiplan Commercial	$56.35

CLOBAZAM 20 MG TABLET [153176]

Facility

$75.14

Service Code	NDC 67386-315-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$41.33
Max. Negotiated Rate	$60.11
Rate for Payer: Cash Price	$41.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.11
Rate for Payer: Health Smart Auto/Commercial	$45.08
Rate for Payer: LLUH Dept of Risk Management WC	$41.33
Rate for Payer: Multiplan Commercial	$56.35

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.36

Service Code	NDC 69238-1532-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
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	$0.27

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.36

Service Code	NDC 69238-1532-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
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	$0.29
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	$0.27

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.76

Service Code	NDC 45802-925-94
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

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.60

Service Code	NDC 51672-1294-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.76

Service Code	NDC 45802-925-94
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

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.60

Service Code	NDC 51672-1294-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.56
Rate for Payer: Aetna of CA Government/Medicare	$1.56
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

CLOBETASOL 0.05 % TOPICAL OINTMENT [9631]

Facility

$0.40

Service Code	NDC 51672-1259-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

CLOBETASOL 0.05 % TOPICAL OINTMENT [9631]

Facility

$0.40

Service Code	NDC 51672-1259-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

CLOMIPRAMINE 25 MG CAPSULE [9635]

Facility

$0.60

Service Code	NDC 51672-4011-6
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

CLOMIPRAMINE 25 MG CAPSULE [9635]

Facility

$0.60

Service Code	NDC 51672-4011-6
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

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.61

Service Code	NDC 50268-173-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.71

Service Code	NDC 60687-861-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
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	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
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	$0.39
Rate for Payer: Multiplan Commercial	$0.53

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.71

Service Code	NDC 60687-861-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
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	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
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	$0.39
Rate for Payer: Multiplan Commercial	$0.53

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.61

Service Code	NDC 50268-173-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.63

Service Code	NDC 0904-7227-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
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	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
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	$0.47

Know your out-of-pocket cost for care.

All Charges