Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION [92854]

Facility

$3.08

Service Code	CPT J7189
Hospital Charge Code	ERX92854
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Cash Price	$1.39
Rate for Payer: Cigna of CA HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.31

COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION [92855]

Facility

$3.08

Service Code	CPT J7189
Hospital Charge Code	ERX92855
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.85
Rate for Payer: Aetna of CA Government/Medicare	$1.85
Rate for Payer: Cash Price	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.31

COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION [92855]

Facility

$3.08

Service Code	CPT J7189
Hospital Charge Code	ERX92855
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Cash Price	$1.39
Rate for Payer: Cigna of CA HMO/PPO	$2.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.31

COBICISTAT 150 MG TABLET [207759]

Facility

$11.33

Service Code	NDC 61958-1401-1
Hospital Charge Code	ERX207759
Hospital Revenue Code	259
Min. Negotiated Rate	$6.23
Max. Negotiated Rate	$8.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.80
Rate for Payer: Aetna of CA Government/Medicare	$6.80
Rate for Payer: Cash Price	$5.10
Rate for Payer: Health Smart Auto/Commercial	$6.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.80
Rate for Payer: LLUH Dept of Risk Management WC	$6.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.50

COBICISTAT 150 MG TABLET [207759]

Facility

$11.33

Service Code	NDC 61958-1401-1
Hospital Charge Code	ERX207759
Hospital Revenue Code	259
Min. Negotiated Rate	$6.23
Max. Negotiated Rate	$9.06
Rate for Payer: Cash Price	$5.10
Rate for Payer: Cigna of CA HMO/PPO	$9.06
Rate for Payer: Health Smart Auto/Commercial	$6.80
Rate for Payer: LLUH Dept of Risk Management WC	$6.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.50

COCAINE 4 % NASAL SOLUTION [221651]

Facility

$73.50

Service Code	CPT C9046
Hospital Charge Code	1734001
Hospital Revenue Code	636
Min. Negotiated Rate	$40.42
Max. Negotiated Rate	$58.80
Rate for Payer: Cash Price	$33.08
Rate for Payer: Cash Price	$29.77
Rate for Payer: Cigna of CA HMO/PPO	$58.80
Rate for Payer: Cigna of CA HMO/PPO	$52.92
Rate for Payer: Health Smart Auto/Commercial	$39.69
Rate for Payer: Health Smart Auto/Commercial	$44.10
Rate for Payer: LLUH Dept of Risk Management WC	$40.42
Rate for Payer: LLUH Dept of Risk Management WC	$36.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.12

COCAINE 4 % NASAL SOLUTION [221651]

Facility

$73.50

Service Code	CPT C9046
Hospital Charge Code	1734001
Hospital Revenue Code	636
Min. Negotiated Rate	$40.42
Max. Negotiated Rate	$55.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.69
Rate for Payer: Aetna of CA Government/Medicare	$39.69
Rate for Payer: Aetna of CA Government/Medicare	$44.10
Rate for Payer: Cash Price	$33.08
Rate for Payer: Cash Price	$29.77
Rate for Payer: Health Smart Auto/Commercial	$44.10
Rate for Payer: Health Smart Auto/Commercial	$39.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.10
Rate for Payer: LLUH Dept of Risk Management WC	$40.42
Rate for Payer: LLUH Dept of Risk Management WC	$36.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.61

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility

$0.06

Service Code	NDC 9999-3252-16
Hospital Charge Code	1716075
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility

$0.14

Service Code	NDC 0121-1775-00
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility

$0.14

Service Code	NDC 0121-1775-05
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility

$0.14

Service Code	NDC 0121-1775-00
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility

$0.06

Service Code	NDC 9999-3252-16
Hospital Charge Code	1716075
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility

$0.14

Service Code	NDC 0121-1775-05
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

CODEINE SULFATE 15 MG TABLET [1801]

Facility

$0.86

Service Code	NDC 0054-0243-24
Hospital Charge Code	1730001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

CODEINE SULFATE 15 MG TABLET [1801]

Facility

$0.86

Service Code	NDC 0054-0243-24
Hospital Charge Code	1730001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

CODEINE SULFATE 30 MG TABLET [1802]

Facility

$1.03

Service Code	NDC 0054-0244-24
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

CODEINE SULFATE 30 MG TABLET [1802]

Facility

$1.43

Service Code	NDC 0527-1698-01
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cigna of CA HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.07

CODEINE SULFATE 30 MG TABLET [1802]

Facility

$1.43

Service Code	NDC 0527-1698-01
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.07

CODEINE SULFATE 30 MG TABLET [1802]

Facility

$1.03

Service Code	NDC 0054-0244-24
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

COENZYME Q10 100 MG CAPSULE [24678]

Facility

$0.16

Service Code	NDC 4098527413
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
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	$0.12

COENZYME Q10 100 MG CAPSULE [24678]

Facility

$0.35

Service Code	NDC 7985407974
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

COENZYME Q10 100 MG CAPSULE [24678]

Facility

$0.35

Service Code	NDC 7985407974
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

COENZYME Q10 100 MG CAPSULE [24678]

Facility

$0.16

Service Code	NDC 4098527413
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
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	$0.07
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	$0.12

COENZYME Q10 100 MG CAPSULE [24678]

Facility

$0.22

Service Code	NDC 8770140816
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

COENZYME Q10 100 MG CAPSULE [24678]

Facility

$0.22

Service Code	NDC 8770140816
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

Know your out-of-pocket cost for care.

All Charges