Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]

Facility

$11.36

Service Code	NDC 51754-1007-3
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$9.09
Rate for Payer: Cash Price	$6.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.09
Rate for Payer: Health Smart Auto/Commercial	$6.82
Rate for Payer: LLUH Dept of Risk Management WC	$6.25
Rate for Payer: Multiplan Commercial	$8.52

CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]

Facility

$11.36

Service Code	NDC 51754-1007-3
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$9.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.82
Rate for Payer: Aetna of CA Government/Medicare	$6.82
Rate for Payer: Cash Price	$6.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.09
Rate for Payer: Health Smart Auto/Commercial	$6.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.82
Rate for Payer: LLUH Dept of Risk Management WC	$6.25
Rate for Payer: Multiplan Commercial	$8.52

CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]

Facility

$11.36

Service Code	NDC 51754-1007-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$9.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.82
Rate for Payer: Aetna of CA Government/Medicare	$6.82
Rate for Payer: Cash Price	$6.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.09
Rate for Payer: Health Smart Auto/Commercial	$6.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.82
Rate for Payer: LLUH Dept of Risk Management WC	$6.25
Rate for Payer: Multiplan Commercial	$8.52

CYSTEINE (L-CYSTEINE) 50 MG/ML INTRAVENOUS SOLUTION [4294]

Facility

$11.36

Service Code	NDC 51754-1007-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$9.09
Rate for Payer: Cash Price	$6.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.09
Rate for Payer: Health Smart Auto/Commercial	$6.82
Rate for Payer: LLUH Dept of Risk Management WC	$6.25
Rate for Payer: Multiplan Commercial	$8.52

CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]

Facility

$1.10

Service Code	HCPCS J9100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cash Price	$0.69
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.94
Rate for Payer: Multiplan Commercial	$0.92
Rate for Payer: Multiplan Commercial	$0.83

CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]

Facility

$1.25

Service Code	HCPCS J9100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.66
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.75
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.92
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Commercial	$0.94

CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]

Facility

$42.16

Service Code	HCPCS J0850
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$23.19
Max. Negotiated Rate	$33.73
Rate for Payer: Cash Price	$23.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.73
Rate for Payer: Health Smart Auto/Commercial	$25.30
Rate for Payer: LLUH Dept of Risk Management WC	$23.19
Rate for Payer: Multiplan Commercial	$31.62

CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]

Facility

$42.16

Service Code	HCPCS J0850
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$23.19
Max. Negotiated Rate	$33.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.30
Rate for Payer: Aetna of CA Government/Medicare	$25.30
Rate for Payer: Cash Price	$23.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.73
Rate for Payer: Health Smart Auto/Commercial	$25.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.30
Rate for Payer: LLUH Dept of Risk Management WC	$23.19
Rate for Payer: Multiplan Commercial	$31.62

DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]

Facility

$3.97

Service Code	NDC 0597-0108-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]

Facility

$3.97

Service Code	NDC 0597-0108-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$2.40

Service Code	NDC 31722-622-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.00

Service Code	NDC 62332-636-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.65
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: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Commercial	$2.25

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.00

Service Code	NDC 62332-636-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.65
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Commercial	$2.25

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$2.40

Service Code	NDC 31722-622-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.37

Service Code	NDC 60687-744-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$11.50
Rate for Payer: Cash Price	$7.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.50
Rate for Payer: Health Smart Auto/Commercial	$8.62
Rate for Payer: LLUH Dept of Risk Management WC	$7.90
Rate for Payer: Multiplan Commercial	$10.78

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$3.97

Service Code	NDC 0597-0355-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$3.97

Service Code	NDC 0597-0355-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.37

Service Code	NDC 60687-744-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.62
Rate for Payer: Aetna of CA Government/Medicare	$8.62
Rate for Payer: Cash Price	$7.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.50
Rate for Payer: Health Smart Auto/Commercial	$8.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.62
Rate for Payer: LLUH Dept of Risk Management WC	$7.90
Rate for Payer: Multiplan Commercial	$10.78

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.37

Service Code	NDC 60687-744-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.62
Rate for Payer: Aetna of CA Government/Medicare	$8.62
Rate for Payer: Cash Price	$7.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.50
Rate for Payer: Health Smart Auto/Commercial	$8.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.62
Rate for Payer: LLUH Dept of Risk Management WC	$7.90
Rate for Payer: Multiplan Commercial	$10.78

Know your out-of-pocket cost for care.

All Charges