Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]

Facility

$33.60

Service Code	HCPCS J0770
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.48
Max. Negotiated Rate	$26.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.15
Rate for Payer: Aetna of CA Government/Medicare	$20.16
Rate for Payer: Aetna of CA Government/Medicare	$20.15
Rate for Payer: Cash Price	$18.48
Rate for Payer: Cash Price	$18.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.87
Rate for Payer: Health Smart Auto/Commercial	$20.15
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.15
Rate for Payer: LLUH Dept of Risk Management WC	$18.47
Rate for Payer: LLUH Dept of Risk Management WC	$18.48
Rate for Payer: Multiplan Commercial	$25.20
Rate for Payer: Multiplan Commercial	$25.19

COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]

Facility

$33.59

Service Code	HCPCS J0770
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$26.87
Rate for Payer: Cash Price	$18.47
Rate for Payer: Cash Price	$18.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.87
Rate for Payer: Health Smart Auto/Commercial	$20.15
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: LLUH Dept of Risk Management WC	$18.47
Rate for Payer: LLUH Dept of Risk Management WC	$18.48
Rate for Payer: Multiplan Commercial	$25.19
Rate for Payer: Multiplan Commercial	$25.20

COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]

Facility

$33.59

Service Code	HCPCS J0770
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$26.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.16
Rate for Payer: Aetna of CA Government/Medicare	$20.16
Rate for Payer: Aetna of CA Government/Medicare	$20.15
Rate for Payer: Cash Price	$18.48
Rate for Payer: Cash Price	$18.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.88
Rate for Payer: Health Smart Auto/Commercial	$20.15
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.16
Rate for Payer: LLUH Dept of Risk Management WC	$18.47
Rate for Payer: LLUH Dept of Risk Management WC	$18.48
Rate for Payer: Multiplan Commercial	$25.20
Rate for Payer: Multiplan Commercial	$25.19

COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]

Facility

$33.60

Service Code	HCPCS J0770
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.48
Max. Negotiated Rate	$26.88
Rate for Payer: Cash Price	$18.48
Rate for Payer: Cash Price	$18.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.88
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: Health Smart Auto/Commercial	$20.15
Rate for Payer: LLUH Dept of Risk Management WC	$18.47
Rate for Payer: LLUH Dept of Risk Management WC	$18.48
Rate for Payer: Multiplan Commercial	$25.19
Rate for Payer: Multiplan Commercial	$25.20

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$12.70

Service Code	NDC 50484-010-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$10.16
Rate for Payer: Cash Price	$6.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.16
Rate for Payer: Health Smart Auto/Commercial	$7.62
Rate for Payer: LLUH Dept of Risk Management WC	$6.99
Rate for Payer: Multiplan Commercial	$9.53

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$10.45

Service Code	NDC 9999-9996-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$8.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.27
Rate for Payer: Aetna of CA Government/Medicare	$6.27
Rate for Payer: Cash Price	$5.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.36
Rate for Payer: Health Smart Auto/Commercial	$6.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.27
Rate for Payer: LLUH Dept of Risk Management WC	$5.75
Rate for Payer: Multiplan Commercial	$7.84

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$12.70

Service Code	NDC 50484-010-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$10.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.62
Rate for Payer: Aetna of CA Government/Medicare	$7.62
Rate for Payer: Cash Price	$6.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.16
Rate for Payer: Health Smart Auto/Commercial	$7.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.62
Rate for Payer: LLUH Dept of Risk Management WC	$6.99
Rate for Payer: Multiplan Commercial	$9.53

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$12.07

Service Code	NDC 50484-010-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$9.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.24
Rate for Payer: Aetna of CA Government/Medicare	$7.24
Rate for Payer: Cash Price	$6.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.66
Rate for Payer: Health Smart Auto/Commercial	$7.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.24
Rate for Payer: LLUH Dept of Risk Management WC	$6.64
Rate for Payer: Multiplan Commercial	$9.05

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$12.07

Service Code	NDC 50484-010-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$9.66
Rate for Payer: Cash Price	$6.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.66
Rate for Payer: Health Smart Auto/Commercial	$7.24
Rate for Payer: LLUH Dept of Risk Management WC	$6.64
Rate for Payer: Multiplan Commercial	$9.05

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]

Facility

$10.45

Service Code	NDC 9999-9996-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$8.36
Rate for Payer: Cash Price	$5.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.36
Rate for Payer: Health Smart Auto/Commercial	$6.27
Rate for Payer: LLUH Dept of Risk Management WC	$5.75
Rate for Payer: Multiplan Commercial	$7.84

COLLOIDAL OATMEAL TOPICAL PACKET [81870]

Facility

$0.80

Service Code	NDC 8137003640
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

COLLOIDAL OATMEAL TOPICAL PACKET [81870]

Facility

$0.80

Service Code	NDC 8137003640
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

COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]

Facility

$0.04

Service Code	NDC 0574030316
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]

Facility

$0.04

Service Code	NDC 0574030316
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.04

Service Code	NDC 0574030216
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.04

Service Code	NDC 0574030216
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.03

Service Code	NDC 0395009416
Hospital Charge Code	901700029
Hospital Revenue Code	259
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 Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.03

Service Code	NDC 0395009416
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$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: Multiplan Commercial	$0.02

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 0395009016
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.10

Service Code	NDC 3877907448
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 3172295901
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 3172295901
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

Know your out-of-pocket cost for care.

All Charges