Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

COLESTIPOL 5 GRAM ORAL PACKET [12218]

Facility

$3.77

Service Code	NDC 0115-5212-18
Hospital Charge Code	ERX12218
Hospital Revenue Code	259
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$3.02
Rate for Payer: Cash Price	$1.70
Rate for Payer: Cigna of CA HMO/PPO	$3.02
Rate for Payer: Health Smart Auto/Commercial	$2.26
Rate for Payer: LLUH Dept of Risk Management WC	$2.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.83

COLESTIPOL 5 GRAM ORAL PACKET [12218]

Facility

$3.77

Service Code	NDC 0115-5212-18
Hospital Charge Code	ERX12218
Hospital Revenue Code	259
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.26
Rate for Payer: Aetna of CA Government/Medicare	$2.26
Rate for Payer: Cash Price	$1.70
Rate for Payer: Health Smart Auto/Commercial	$2.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.26
Rate for Payer: LLUH Dept of Risk Management WC	$2.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.83

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

Facility

$33.59

Service Code	CPT J0770
Hospital Charge Code	ERX4080399
Hospital Revenue Code	636
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$26.87
Rate for Payer: Cash Price	$15.12
Rate for Payer: Cash Price	$15.12
Rate for Payer: Cigna of CA HMO/PPO	$26.88
Rate for Payer: Cigna of CA HMO/PPO	$26.87
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 Beech St/Commercial/PHCS	$25.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.20

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

Facility

$33.59

Service Code	CPT J0770
Hospital Charge Code	ERX4080399
Hospital Revenue Code	636
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$25.19
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	$15.12
Rate for Payer: Cash Price	$15.12
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	$18.48
Rate for Payer: LLUH Dept of Risk Management WC	$18.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.19

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

Facility

$33.59

Service Code	CPT J0770
Hospital Charge Code	ERX4082134
Hospital Revenue Code	636
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$25.19
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	$15.12
Rate for Payer: Cash Price	$15.12
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: Health Smart Auto/Commercial	$20.15
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	$18.48
Rate for Payer: LLUH Dept of Risk Management WC	$18.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.20

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

Facility

$33.59

Service Code	CPT J0770
Hospital Charge Code	ERX4082134
Hospital Revenue Code	636
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$26.87
Rate for Payer: Cash Price	$15.12
Rate for Payer: Cigna of CA HMO/PPO	$26.87
Rate for Payer: Cigna of CA 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: Cash Price	$15.12
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 Beech St/Commercial/PHCS	$25.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.19

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

Facility

$10.95

Service Code	NDC 50484-010-90
Hospital Charge Code	NDG9682B
Hospital Revenue Code	259
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$8.76
Rate for Payer: Cash Price	$4.93
Rate for Payer: Cigna of CA HMO/PPO	$8.76
Rate for Payer: Health Smart Auto/Commercial	$6.57
Rate for Payer: LLUH Dept of Risk Management WC	$6.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.21

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

Facility

$11.52

Service Code	NDC 50484-010-30
Hospital Charge Code	1743273
Hospital Revenue Code	259
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$9.22
Rate for Payer: Cash Price	$5.18
Rate for Payer: Cigna of CA HMO/PPO	$9.22
Rate for Payer: Health Smart Auto/Commercial	$6.91
Rate for Payer: LLUH Dept of Risk Management WC	$6.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.64

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

Facility

$11.52

Service Code	NDC 50484-010-30
Hospital Charge Code	1743273
Hospital Revenue Code	259
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.91
Rate for Payer: Aetna of CA Government/Medicare	$6.91
Rate for Payer: Cash Price	$5.18
Rate for Payer: Health Smart Auto/Commercial	$6.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.91
Rate for Payer: LLUH Dept of Risk Management WC	$6.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.64

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

Facility

$10.95

Service Code	NDC 50484-010-90
Hospital Charge Code	NDG9682B
Hospital Revenue Code	259
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$8.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.57
Rate for Payer: Aetna of CA Government/Medicare	$6.57
Rate for Payer: Cash Price	$4.93
Rate for Payer: Health Smart Auto/Commercial	$6.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.57
Rate for Payer: LLUH Dept of Risk Management WC	$6.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.21

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

Facility

$0.05

Service Code	NDC 574030416
Hospital Charge Code	NDG120589
Hospital Revenue Code	271
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

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

Facility

$0.05

Service Code	NDC 574030416
Hospital Charge Code	NDG120589
Hospital Revenue Code	271
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

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

Facility

$0.05

Service Code	NDC 574030316
Hospital Charge Code	NDG211818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

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

Facility

$0.05

Service Code	NDC 574030316
Hospital Charge Code	NDG211818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

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

Facility

$0.04

Service Code	NDC 395009416
Hospital Charge Code	NDG120588
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: 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 Beech St/Commercial/PHCS	$0.03

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

Facility

$0.04

Service Code	NDC 395009416
Hospital Charge Code	NDG120588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

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

Facility

$0.05

Service Code	NDC 574030216
Hospital Charge Code	NDG120588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

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

Facility

$0.05

Service Code	NDC 574030216
Hospital Charge Code	NDG120588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 395009016
Hospital Charge Code	NDG120589
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: 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 Beech St/Commercial/PHCS	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.05

Service Code	NDC 3172295901
Hospital Charge Code	NDG120589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.10

Service Code	NDC 3877907448
Hospital Charge Code	NDG120589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 395009016
Hospital Charge Code	NDG120589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.10

Service Code	NDC 3877907448
Hospital Charge Code	NDG120589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.05

Service Code	NDC 574030416
Hospital Charge Code	NDG120589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.05

Service Code	NDC 574030416
Hospital Charge Code	NDG120589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

Know your out-of-pocket cost for care.

All Charges