Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]

Facility

$5.30

Service Code	NDC 9994-0802-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.18
Rate for Payer: Aetna of CA Government/Medicare	$3.18
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

CYCLOSPORINE 0.05 % EYE DROPS [216389]

Facility

$140.86

Service Code	NDC 0023-5301-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$77.47
Max. Negotiated Rate	$112.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.52
Rate for Payer: Aetna of CA Government/Medicare	$84.52
Rate for Payer: Cash Price	$77.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.69
Rate for Payer: Health Smart Auto/Commercial	$84.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.52
Rate for Payer: LLUH Dept of Risk Management WC	$77.47
Rate for Payer: Multiplan Commercial	$105.64

CYCLOSPORINE 0.05 % EYE DROPS [216389]

Facility

$140.86

Service Code	NDC 0023-5301-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$77.47
Max. Negotiated Rate	$112.69
Rate for Payer: Cash Price	$77.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.69
Rate for Payer: Health Smart Auto/Commercial	$84.52
Rate for Payer: LLUH Dept of Risk Management WC	$77.47
Rate for Payer: Multiplan Commercial	$105.64

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$3.22

Service Code	NDC 68180-214-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.93
Rate for Payer: Aetna of CA Government/Medicare	$1.93
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$3.83

Service Code	NDC 73043-005-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Cash Price	$2.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.87

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$5.60

Service Code	NDC 60505-6202-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$5.60

Service Code	NDC 60505-6202-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.36
Rate for Payer: Aetna of CA Government/Medicare	$3.36
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$3.22

Service Code	NDC 68180-214-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$3.83

Service Code	NDC 73043-005-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$2.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.87

CYCLOSPORINE 100 MG CAPSULE [9706]

Facility

$21.94

Service Code	HCPCS J7502
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.07
Max. Negotiated Rate	$17.55
Rate for Payer: Cash Price	$12.06
Rate for Payer: Cash Price	$9.32
Rate for Payer: Cash Price	$12.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.56
Rate for Payer: Health Smart Auto/Commercial	$10.17
Rate for Payer: Health Smart Auto/Commercial	$13.15
Rate for Payer: Health Smart Auto/Commercial	$13.16
Rate for Payer: LLUH Dept of Risk Management WC	$12.07
Rate for Payer: LLUH Dept of Risk Management WC	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$12.05
Rate for Payer: Multiplan Commercial	$12.71
Rate for Payer: Multiplan Commercial	$16.43
Rate for Payer: Multiplan Commercial	$16.45

CYCLOSPORINE 100 MG CAPSULE [9706]

Facility

$21.94

Service Code	HCPCS J7502
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.07
Max. Negotiated Rate	$17.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.15
Rate for Payer: Aetna of CA Government/Medicare	$10.17
Rate for Payer: Aetna of CA Government/Medicare	$13.16
Rate for Payer: Aetna of CA Government/Medicare	$13.15
Rate for Payer: Cash Price	$9.32
Rate for Payer: Cash Price	$12.06
Rate for Payer: Cash Price	$12.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.53
Rate for Payer: Health Smart Auto/Commercial	$10.17
Rate for Payer: Health Smart Auto/Commercial	$13.15
Rate for Payer: Health Smart Auto/Commercial	$13.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.16
Rate for Payer: LLUH Dept of Risk Management WC	$12.05
Rate for Payer: LLUH Dept of Risk Management WC	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$12.07
Rate for Payer: Multiplan Commercial	$12.71
Rate for Payer: Multiplan Commercial	$16.43
Rate for Payer: Multiplan Commercial	$16.45

CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]

Facility

$17.08

Service Code	HCPCS J7516
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$13.66
Rate for Payer: Cash Price	$9.40
Rate for Payer: Cash Price	$9.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.66
Rate for Payer: Health Smart Auto/Commercial	$10.25
Rate for Payer: Health Smart Auto/Commercial	$10.25
Rate for Payer: LLUH Dept of Risk Management WC	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$9.39
Rate for Payer: Multiplan Commercial	$12.81
Rate for Payer: Multiplan Commercial	$12.82

CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]

Facility

$17.08

Service Code	HCPCS J7516
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$13.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.25
Rate for Payer: Aetna of CA Government/Medicare	$10.25
Rate for Payer: Aetna of CA Government/Medicare	$10.25
Rate for Payer: Cash Price	$9.40
Rate for Payer: Cash Price	$9.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.67
Rate for Payer: Health Smart Auto/Commercial	$10.25
Rate for Payer: Health Smart Auto/Commercial	$10.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.25
Rate for Payer: LLUH Dept of Risk Management WC	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$9.39
Rate for Payer: Multiplan Commercial	$12.82
Rate for Payer: Multiplan Commercial	$12.81

CYCLOSPORINE 25 MG CAPSULE [9707]

Facility

$4.25

Service Code	HCPCS J7515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$3.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.45
Rate for Payer: Aetna of CA Government/Medicare	$3.45
Rate for Payer: Aetna of CA Government/Medicare	$3.29
Rate for Payer: Aetna of CA Government/Medicare	$2.55
Rate for Payer: Aetna of CA Government/Medicare	$3.34
Rate for Payer: Cash Price	$2.34
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cash Price	$3.02
Rate for Payer: Cash Price	$3.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.60
Rate for Payer: Health Smart Auto/Commercial	$3.45
Rate for Payer: Health Smart Auto/Commercial	$3.34
Rate for Payer: Health Smart Auto/Commercial	$3.29
Rate for Payer: Health Smart Auto/Commercial	$2.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.55
Rate for Payer: LLUH Dept of Risk Management WC	$3.16
Rate for Payer: LLUH Dept of Risk Management WC	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$3.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Commercial	$4.12
Rate for Payer: Multiplan Commercial	$4.17
Rate for Payer: Multiplan Commercial	$4.31
Rate for Payer: Multiplan Commercial	$3.19

CYCLOSPORINE 25 MG CAPSULE [9707]

Facility

$4.25

Service Code	HCPCS J7515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$3.40
Rate for Payer: Cash Price	$2.34
Rate for Payer: Cash Price	$3.06
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cash Price	$3.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.60
Rate for Payer: Health Smart Auto/Commercial	$3.45
Rate for Payer: Health Smart Auto/Commercial	$2.55
Rate for Payer: Health Smart Auto/Commercial	$3.34
Rate for Payer: Health Smart Auto/Commercial	$3.29
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$3.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.16
Rate for Payer: Multiplan Commercial	$4.12
Rate for Payer: Multiplan Commercial	$3.19
Rate for Payer: Multiplan Commercial	$4.31
Rate for Payer: Multiplan Commercial	$4.17

CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]

Facility

$8.81

Service Code	HCPCS J7502
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$7.05
Rate for Payer: Cash Price	$4.85
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Health Smart Auto/Commercial	$5.29
Rate for Payer: LLUH Dept of Risk Management WC	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Commercial	$2.25
Rate for Payer: Multiplan Commercial	$3.96
Rate for Payer: Multiplan Commercial	$6.61

CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]

Facility

$8.81

Service Code	HCPCS J7502
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$7.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.17
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$5.29
Rate for Payer: Aetna of CA Government/Medicare	$3.17
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cash Price	$4.85
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Health Smart Auto/Commercial	$5.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.29
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$4.85
Rate for Payer: Multiplan Commercial	$2.25
Rate for Payer: Multiplan Commercial	$3.96
Rate for Payer: Multiplan Commercial	$6.61

CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]

Facility

$9.96

Service Code	HCPCS J7502
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.40
Rate for Payer: Aetna of CA Government/Medicare	$9.23
Rate for Payer: Aetna of CA Government/Medicare	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$3.40
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$5.48
Rate for Payer: Cash Price	$3.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.53
Rate for Payer: Health Smart Auto/Commercial	$9.23
Rate for Payer: Health Smart Auto/Commercial	$3.40
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$11.54
Rate for Payer: Multiplan Commercial	$4.25
Rate for Payer: Multiplan Commercial	$7.47

CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]

Facility

$9.96

Service Code	HCPCS J7502
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Cash Price	$5.48
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$3.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.30
Rate for Payer: Health Smart Auto/Commercial	$9.23
Rate for Payer: Health Smart Auto/Commercial	$3.40
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$3.11
Rate for Payer: Multiplan Commercial	$11.54
Rate for Payer: Multiplan Commercial	$4.25
Rate for Payer: Multiplan Commercial	$7.47

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$1.32

Service Code	HCPCS J7515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$1.32

Service Code	HCPCS J7515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.07

Service Code	NDC 50742-190-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

Know your out-of-pocket cost for care.

All Charges