Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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 0395009016
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 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

CONJUGATED ESTROGENS 0.3 MG TABLET [9973]

Facility

$8.49

Service Code	NDC 0046-1100-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.79
Rate for Payer: Health Smart Auto/Commercial	$5.09
Rate for Payer: LLUH Dept of Risk Management WC	$4.67
Rate for Payer: Multiplan Commercial	$6.37

CONJUGATED ESTROGENS 0.3 MG TABLET [9973]

Facility

$8.49

Service Code	NDC 0046-1100-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.09
Rate for Payer: Aetna of CA Government/Medicare	$5.09
Rate for Payer: Cash Price	$4.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.79
Rate for Payer: Health Smart Auto/Commercial	$5.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.09
Rate for Payer: LLUH Dept of Risk Management WC	$4.67
Rate for Payer: Multiplan Commercial	$6.37

CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]

Facility

$18.43

Service Code	NDC 0046-0872-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$14.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.06
Rate for Payer: Aetna of CA Government/Medicare	$11.06
Rate for Payer: Cash Price	$10.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.74
Rate for Payer: Health Smart Auto/Commercial	$11.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.06
Rate for Payer: LLUH Dept of Risk Management WC	$10.14
Rate for Payer: Multiplan Commercial	$13.82

CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]

Facility

$18.43

Service Code	NDC 0046-0872-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$14.74
Rate for Payer: Cash Price	$10.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.74
Rate for Payer: Health Smart Auto/Commercial	$11.06
Rate for Payer: LLUH Dept of Risk Management WC	$10.14
Rate for Payer: Multiplan Commercial	$13.82

CONJUGATED ESTROGENS 0.625 MG TABLET [9974]

Facility

$8.49

Service Code	NDC 0046-1102-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.09
Rate for Payer: Aetna of CA Government/Medicare	$5.09
Rate for Payer: Cash Price	$4.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.79
Rate for Payer: Health Smart Auto/Commercial	$5.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.09
Rate for Payer: LLUH Dept of Risk Management WC	$4.67
Rate for Payer: Multiplan Commercial	$6.37

CONJUGATED ESTROGENS 0.625 MG TABLET [9974]

Facility

$8.49

Service Code	NDC 0046-1102-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.79
Rate for Payer: Health Smart Auto/Commercial	$5.09
Rate for Payer: LLUH Dept of Risk Management WC	$4.67
Rate for Payer: Multiplan Commercial	$6.37

CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]

Facility

$452.26

Service Code	HCPCS J1410
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$248.74
Max. Negotiated Rate	$361.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$271.36
Rate for Payer: Aetna of CA Government/Medicare	$271.36
Rate for Payer: Cash Price	$248.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$361.81
Rate for Payer: Health Smart Auto/Commercial	$271.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$271.36
Rate for Payer: LLUH Dept of Risk Management WC	$248.74
Rate for Payer: Multiplan Commercial	$339.19

CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]

Facility

$452.26

Service Code	HCPCS J1410
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$248.74
Max. Negotiated Rate	$361.81
Rate for Payer: Cash Price	$248.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$361.81
Rate for Payer: Health Smart Auto/Commercial	$271.36
Rate for Payer: LLUH Dept of Risk Management WC	$248.74
Rate for Payer: Multiplan Commercial	$339.19

COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]

Facility

$2.60

Service Code	NDC 9994-0804-25
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

COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]

Facility

$2.60

Service Code	NDC 9994-0804-25
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

COPPER GLUCONATE 2 MG TABLET [112194]

Facility

$0.09

Service Code	NDC 0536143901
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

COPPER GLUCONATE 2 MG TABLET [112194]

Facility

$0.09

Service Code	NDC 0536143901
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
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	$0.05
Rate for Payer: Multiplan Commercial	$0.07

COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]

Facility

$0.25

Service Code	NDC 9994-0804-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]

Facility

$0.25

Service Code	NDC 9994-0804-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]

Facility

$96.24

Service Code	HCPCS J0834
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$52.93
Max. Negotiated Rate	$76.99
Rate for Payer: Cash Price	$52.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.99
Rate for Payer: Health Smart Auto/Commercial	$57.74
Rate for Payer: LLUH Dept of Risk Management WC	$52.93
Rate for Payer: Multiplan Commercial	$72.18

COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]

Facility

$96.24

Service Code	HCPCS J0834
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$52.93
Max. Negotiated Rate	$76.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.74
Rate for Payer: Aetna of CA Government/Medicare	$57.74
Rate for Payer: Cash Price	$52.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.99
Rate for Payer: Health Smart Auto/Commercial	$57.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.74
Rate for Payer: LLUH Dept of Risk Management WC	$52.93
Rate for Payer: Multiplan Commercial	$72.18

CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]

Facility

$294.35

Service Code	HCPCS J0791
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$161.89
Max. Negotiated Rate	$235.48
Rate for Payer: Cash Price	$161.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$235.48
Rate for Payer: Health Smart Auto/Commercial	$176.61
Rate for Payer: LLUH Dept of Risk Management WC	$161.89
Rate for Payer: Multiplan Commercial	$220.76

CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]

Facility

$294.35

Service Code	HCPCS J0791
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$161.89
Max. Negotiated Rate	$235.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$176.61
Rate for Payer: Aetna of CA Government/Medicare	$176.61
Rate for Payer: Cash Price	$161.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$235.48
Rate for Payer: Health Smart Auto/Commercial	$176.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$176.61
Rate for Payer: LLUH Dept of Risk Management WC	$161.89
Rate for Payer: Multiplan Commercial	$220.76

CRIZOTINIB 250 MG CAPSULE [153216]

Facility

$475.46

Service Code	NDC 0069-8140-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$261.50
Max. Negotiated Rate	$380.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$285.28
Rate for Payer: Aetna of CA Government/Medicare	$285.28
Rate for Payer: Cash Price	$261.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$380.37
Rate for Payer: Health Smart Auto/Commercial	$285.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$285.28
Rate for Payer: LLUH Dept of Risk Management WC	$261.50
Rate for Payer: Multiplan Commercial	$356.60

CRIZOTINIB 250 MG CAPSULE [153216]

Facility

$475.46

Service Code	NDC 0069-8140-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$261.50
Max. Negotiated Rate	$380.37
Rate for Payer: Cash Price	$261.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$380.37
Rate for Payer: Health Smart Auto/Commercial	$285.28
Rate for Payer: LLUH Dept of Risk Management WC	$261.50
Rate for Payer: Multiplan Commercial	$356.60

CROMOLYN 4 % EYE DROPS [9691]

Facility

$2.70

Service Code	NDC 61314-237-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.62
Rate for Payer: Aetna of CA Government/Medicare	$1.62
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.02

CROMOLYN 4 % EYE DROPS [9691]

Facility

$2.70

Service Code	NDC 61314-237-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.16
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.02

Know your out-of-pocket cost for care.

All Charges