Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

CLOMIPRAMINE 50 MG CAPSULE [1754]

Facility

$0.60

Service Code	NDC 27241-211-30
Hospital Charge Code	1711837
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 50 MG CAPSULE [1754]

Facility

$0.60

Service Code	NDC 27241-211-30
Hospital Charge Code	1711837
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

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.71

Service Code	NDC 60687-544-01
Hospital Charge Code	1730122
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
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	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.05

Service Code	NDC 16729-136-00
Hospital Charge Code	1730122
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.05

Service Code	NDC 16729-136-00
Hospital Charge Code	1730122
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.71

Service Code	NDC 60687-544-11
Hospital Charge Code	1730122
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
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	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.71

Service Code	NDC 60687-544-11
Hospital Charge Code	1730122
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 0.5 MG TABLET [9637]

Facility

$0.71

Service Code	NDC 60687-544-01
Hospital Charge Code	1730122
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 1 MG TABLET [9638]

Facility

$0.05

Service Code	NDC 16729-137-00
Hospital Charge Code	1730123
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

CLONAZEPAM 1 MG TABLET [9638]

Facility

$0.71

Service Code	NDC 60687-555-01
Hospital Charge Code	1730123
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 1 MG TABLET [9638]

Facility

$0.05

Service Code	NDC 16729-137-00
Hospital Charge Code	1730123
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

CLONAZEPAM 1 MG TABLET [9638]

Facility

$0.71

Service Code	NDC 60687-555-11
Hospital Charge Code	1730123
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 1 MG TABLET [9638]

Facility

$0.71

Service Code	NDC 60687-555-11
Hospital Charge Code	1730123
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
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	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 1 MG TABLET [9638]

Facility

$0.71

Service Code	NDC 60687-555-01
Hospital Charge Code	1730123
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
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	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

CLONAZEPAM 2 MG TABLET [9639]

Facility

$0.08

Service Code	NDC 16729-138-00
Hospital Charge Code	1730121
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

CLONAZEPAM 2 MG TABLET [9639]

Facility

$0.08

Service Code	NDC 16729-138-00
Hospital Charge Code	1730121
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

CLONAZEPAM ORAL SUSPENSION COMPOUND 0.1 MG/ML [4080257]

Facility

$1.18

Service Code	NDC 9994-0802-57
Hospital Charge Code	1715277
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

CLONAZEPAM ORAL SUSPENSION COMPOUND 0.1 MG/ML [4080257]

Facility

$1.18

Service Code	NDC 9994-0802-57
Hospital Charge Code	1715277
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]

Facility

$15.92

Service Code	NDC 51862-453-01
Hospital Charge Code	1743456
Hospital Revenue Code	259
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$11.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.55
Rate for Payer: Aetna of CA Government/Medicare	$9.55
Rate for Payer: Cash Price	$7.16
Rate for Payer: Health Smart Auto/Commercial	$9.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.55
Rate for Payer: LLUH Dept of Risk Management WC	$8.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.94

CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]

Facility

$15.92

Service Code	NDC 51862-453-01
Hospital Charge Code	1743456
Hospital Revenue Code	259
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$12.74
Rate for Payer: Cash Price	$7.16
Rate for Payer: Cigna of CA HMO/PPO	$12.74
Rate for Payer: Health Smart Auto/Commercial	$9.55
Rate for Payer: LLUH Dept of Risk Management WC	$8.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.94

CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]

Facility

$15.92

Service Code	NDC 51862-453-04
Hospital Charge Code	1743456
Hospital Revenue Code	259
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$11.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.55
Rate for Payer: Aetna of CA Government/Medicare	$9.55
Rate for Payer: Cash Price	$7.16
Rate for Payer: Health Smart Auto/Commercial	$9.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.55
Rate for Payer: LLUH Dept of Risk Management WC	$8.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.94

CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [27505]

Facility

$15.92

Service Code	NDC 51862-453-04
Hospital Charge Code	1743456
Hospital Revenue Code	259
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$12.74
Rate for Payer: Health Smart Auto/Commercial	$9.55
Rate for Payer: Cash Price	$7.16
Rate for Payer: Cigna of CA HMO/PPO	$12.74
Rate for Payer: LLUH Dept of Risk Management WC	$8.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.94

CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH [27506]

Facility

$26.80

Service Code	NDC 51862-454-01
Hospital Charge Code	1743457
Hospital Revenue Code	259
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$21.44
Rate for Payer: Cash Price	$12.06
Rate for Payer: Cigna of CA HMO/PPO	$21.44
Rate for Payer: Health Smart Auto/Commercial	$16.08
Rate for Payer: LLUH Dept of Risk Management WC	$14.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.10

Know your out-of-pocket cost for care.

All Charges