Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CLOBAZAM 10 MG/4 ML ORAL SUSPENSION [201477]

Facility

$0.56

Service Code	NDC 69238-1535-2
Hospital Charge Code	NDG201477
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.42

CLOBAZAM 10 MG TABLET [153175]

Facility

$0.37

Service Code	NDC 69238-1305-1
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.28

CLOBAZAM 10 MG TABLET [153175]

Facility

$3.12

Service Code	NDC 60687-423-21
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.34
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	$1.40
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 Beech St/Commercial/PHCS	$2.34

CLOBAZAM 10 MG TABLET [153175]

Facility

$3.12

Service Code	NDC 60687-423-11
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Cash Price	$1.40
Rate for Payer: Cigna of CA HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.34

CLOBAZAM 10 MG TABLET [153175]

Facility

$3.12

Service Code	NDC 60687-423-11
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.34
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	$1.40
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 Beech St/Commercial/PHCS	$2.34

CLOBAZAM 10 MG TABLET [153175]

Facility

$0.37

Service Code	NDC 69238-1305-1
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
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	$0.17
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 Beech St/Commercial/PHCS	$0.28

CLOBAZAM 10 MG TABLET [153175]

Facility

$1.74

Service Code	NDC 42571-315-01
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.30

CLOBAZAM 10 MG TABLET [153175]

Facility

$3.12

Service Code	NDC 60687-423-21
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Cash Price	$1.40
Rate for Payer: Cigna of CA HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.34

CLOBAZAM 10 MG TABLET [153175]

Facility

$1.74

Service Code	NDC 42571-315-01
Hospital Charge Code	1730194
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.39
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cigna of CA HMO/PPO	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.30

CLOBAZAM 20 MG TABLET [153176]

Facility

$65.95

Service Code	NDC 67386-315-01
Hospital Charge Code	ERX153176
Hospital Revenue Code	259
Min. Negotiated Rate	$36.27
Max. Negotiated Rate	$52.76
Rate for Payer: Cash Price	$29.68
Rate for Payer: Cigna of CA HMO/PPO	$52.76
Rate for Payer: Health Smart Auto/Commercial	$39.57
Rate for Payer: LLUH Dept of Risk Management WC	$36.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.46

CLOBAZAM 20 MG TABLET [153176]

Facility

$65.95

Service Code	NDC 67386-315-01
Hospital Charge Code	ERX153176
Hospital Revenue Code	259
Min. Negotiated Rate	$36.27
Max. Negotiated Rate	$49.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.57
Rate for Payer: Aetna of CA Government/Medicare	$39.57
Rate for Payer: Cash Price	$29.68
Rate for Payer: Health Smart Auto/Commercial	$39.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.57
Rate for Payer: LLUH Dept of Risk Management WC	$36.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.46

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-1
Hospital Charge Code	NDG9630
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.17

Service Code	NDC 42291-076-15
Hospital Charge Code	NDG9630
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

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-2
Hospital Charge Code	1743720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
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	$0.36
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 Beech St/Commercial/PHCS	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-1
Hospital Charge Code	NDG9630
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
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	$0.36
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 Beech St/Commercial/PHCS	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.80

Service Code	NDC 51672-1258-2
Hospital Charge Code	1743720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.60

CLOBETASOL 0.05 % TOPICAL CREAM [9630]

Facility

$0.17

Service Code	NDC 42291-076-15
Hospital Charge Code	NDG9630
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

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.60

Service Code	NDC 51672-1294-2
Hospital Charge Code	NDG2152
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.95
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	$1.17
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 Beech St/Commercial/PHCS	$1.95

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.60

Service Code	NDC 51672-1294-2
Hospital Charge Code	NDG2152
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.95

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.76

Service Code	NDC 45802-925-94
Hospital Charge Code	NDG2152
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.07
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	$1.24
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 Beech St/Commercial/PHCS	$2.07

CLOBETASOL 0.05 % TOPICAL GEL [13203]

Facility

$2.76

Service Code	NDC 45802-925-94
Hospital Charge Code	NDG2152
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.21
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.07

CLOMIPRAMINE 25 MG CAPSULE [9635]

Facility

$5.83

Service Code	NDC 59746-710-30
Hospital Charge Code	1711836
Hospital Revenue Code	259
Min. Negotiated Rate	$3.21
Max. Negotiated Rate	$4.66
Rate for Payer: Cash Price	$2.62
Rate for Payer: Cigna of CA HMO/PPO	$4.66
Rate for Payer: Health Smart Auto/Commercial	$3.50
Rate for Payer: LLUH Dept of Risk Management WC	$3.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.37

CLOMIPRAMINE 25 MG CAPSULE [9635]

Facility

$5.83

Service Code	NDC 59746-710-30
Hospital Charge Code	1711836
Hospital Revenue Code	259
Min. Negotiated Rate	$3.21
Max. Negotiated Rate	$4.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.50
Rate for Payer: Aetna of CA Government/Medicare	$3.50
Rate for Payer: Cash Price	$2.62
Rate for Payer: Health Smart Auto/Commercial	$3.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.50
Rate for Payer: LLUH Dept of Risk Management WC	$3.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.37

CLOMIPRAMINE 25 MG CAPSULE [9635]

Facility

$0.60

Service Code	NDC 27241-210-30
Hospital Charge Code	1711836
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

CLOMIPRAMINE 25 MG CAPSULE [9635]

Facility

$8.09

Service Code	NDC 51672-4011-6
Hospital Charge Code	1711836
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna of CA HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.07

Know your out-of-pocket cost for care.

All Charges