Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

CONJUGATED ESTROGENS 0.3 MG TABLET [9973]

Facility

$8.05

Service Code	NDC 0046-1100-81
Hospital Charge Code	1710526
Hospital Revenue Code	259
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$6.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.83
Rate for Payer: Aetna of CA Government/Medicare	$4.83
Rate for Payer: Cash Price	$3.62
Rate for Payer: Health Smart Auto/Commercial	$4.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.83
Rate for Payer: LLUH Dept of Risk Management WC	$4.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.04

CONJUGATED ESTROGENS 0.3 MG TABLET [9973]

Facility

$8.05

Service Code	NDC 0046-1100-81
Hospital Charge Code	1710526
Hospital Revenue Code	259
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$6.44
Rate for Payer: Cash Price	$3.62
Rate for Payer: Cigna of CA HMO/PPO	$6.44
Rate for Payer: Health Smart Auto/Commercial	$4.83
Rate for Payer: LLUH Dept of Risk Management WC	$4.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.04

CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]

Facility

$17.48

Service Code	NDC 0046-0872-21
Hospital Charge Code	1743781
Hospital Revenue Code	259
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$13.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.49
Rate for Payer: Aetna of CA Government/Medicare	$10.49
Rate for Payer: Cash Price	$7.87
Rate for Payer: Health Smart Auto/Commercial	$10.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.49
Rate for Payer: LLUH Dept of Risk Management WC	$9.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.11

CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]

Facility

$17.48

Service Code	NDC 0046-0872-21
Hospital Charge Code	1743781
Hospital Revenue Code	259
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$13.98
Rate for Payer: Cash Price	$7.87
Rate for Payer: Cigna of CA HMO/PPO	$13.98
Rate for Payer: Health Smart Auto/Commercial	$10.49
Rate for Payer: LLUH Dept of Risk Management WC	$9.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.11

CONJUGATED ESTROGENS 0.625 MG TABLET [9974]

Facility

$8.05

Service Code	NDC 0046-1102-81
Hospital Charge Code	1710519
Hospital Revenue Code	259
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$6.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.83
Rate for Payer: Aetna of CA Government/Medicare	$4.83
Rate for Payer: Cash Price	$3.62
Rate for Payer: Health Smart Auto/Commercial	$4.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.83
Rate for Payer: LLUH Dept of Risk Management WC	$4.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.04

CONJUGATED ESTROGENS 0.625 MG TABLET [9974]

Facility

$8.05

Service Code	NDC 0046-1102-81
Hospital Charge Code	1710519
Hospital Revenue Code	259
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$6.44
Rate for Payer: Cash Price	$3.62
Rate for Payer: Cigna of CA HMO/PPO	$6.44
Rate for Payer: Health Smart Auto/Commercial	$4.83
Rate for Payer: LLUH Dept of Risk Management WC	$4.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.04

CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]

Facility

$428.80

Service Code	CPT J1410
Hospital Charge Code	1720160
Hospital Revenue Code	636
Min. Negotiated Rate	$235.84
Max. Negotiated Rate	$343.04
Rate for Payer: Cash Price	$192.96
Rate for Payer: Cigna of CA HMO/PPO	$343.04
Rate for Payer: Health Smart Auto/Commercial	$257.28
Rate for Payer: LLUH Dept of Risk Management WC	$235.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$321.60

CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]

Facility

$428.80

Service Code	CPT J1410
Hospital Charge Code	1720160
Hospital Revenue Code	636
Min. Negotiated Rate	$235.84
Max. Negotiated Rate	$321.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$257.28
Rate for Payer: Aetna of CA Government/Medicare	$257.28
Rate for Payer: Cash Price	$192.96
Rate for Payer: Health Smart Auto/Commercial	$257.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$257.28
Rate for Payer: LLUH Dept of Risk Management WC	$235.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$321.60

COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]

Facility

$6,180.48

Service Code	CPT J9057
Hospital Charge Code	ERX219718
Hospital Revenue Code	636
Min. Negotiated Rate	$3,399.26
Max. Negotiated Rate	$4,635.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,708.29
Rate for Payer: Aetna of CA Government/Medicare	$3,708.29
Rate for Payer: Cash Price	$2,781.22
Rate for Payer: Health Smart Auto/Commercial	$3,708.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,708.29
Rate for Payer: LLUH Dept of Risk Management WC	$3,399.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,635.36

COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]

Facility

$6,180.48

Service Code	CPT J9057
Hospital Charge Code	ERX219718
Hospital Revenue Code	636
Min. Negotiated Rate	$3,399.26
Max. Negotiated Rate	$4,944.38
Rate for Payer: Cash Price	$2,781.22
Rate for Payer: Cigna of CA HMO/PPO	$4,944.38
Rate for Payer: Health Smart Auto/Commercial	$3,708.29
Rate for Payer: LLUH Dept of Risk Management WC	$3,399.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,635.36

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

Facility

$2.60

Service Code	NDC 9994-0804-25
Hospital Charge Code	1715158
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.95
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	$1.17
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 Beech St/Commercial/PHCS	$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	1715158
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.95

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

Facility

$0.25

Service Code	NDC 9994-0804-26
Hospital Charge Code	1715311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
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	$0.11
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 Beech St/Commercial/PHCS	$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	1715311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.19

CORTICOTROPIN 80 UNIT/ML INJECTION GEL [9685]

Facility

$10,248.72

Service Code	CPT J0801
Hospital Charge Code	NDG9685
Hospital Revenue Code	636
Min. Negotiated Rate	$5,636.80
Max. Negotiated Rate	$8,198.98
Rate for Payer: Cash Price	$4,611.92
Rate for Payer: Cash Price	$3,675.67
Rate for Payer: Cigna of CA HMO/PPO	$8,198.98
Rate for Payer: Cigna of CA HMO/PPO	$6,534.53
Rate for Payer: Health Smart Auto/Commercial	$4,900.90
Rate for Payer: Health Smart Auto/Commercial	$6,149.23
Rate for Payer: LLUH Dept of Risk Management WC	$5,636.80
Rate for Payer: LLUH Dept of Risk Management WC	$4,492.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,686.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,126.12

CORTICOTROPIN 80 UNIT/ML INJECTION GEL [9685]

Facility

$8,168.16

Service Code	CPT J0801
Hospital Charge Code	NDG9685
Hospital Revenue Code	636
Min. Negotiated Rate	$4,492.49
Max. Negotiated Rate	$6,126.12
Rate for Payer: Cash Price	$3,675.67
Rate for Payer: Cash Price	$4,611.92
Rate for Payer: Health Smart Auto/Commercial	$4,900.90
Rate for Payer: Health Smart Auto/Commercial	$6,149.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4,900.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6,149.23
Rate for Payer: Aetna of CA Government/Medicare	$4,900.90
Rate for Payer: Aetna of CA Government/Medicare	$6,149.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6,149.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4,900.90
Rate for Payer: LLUH Dept of Risk Management WC	$4,492.49
Rate for Payer: LLUH Dept of Risk Management WC	$5,636.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,686.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,126.12

COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]

Facility

$96.24

Service Code	CPT J0834
Hospital Charge Code	1754264
Hospital Revenue Code	636
Min. Negotiated Rate	$52.93
Max. Negotiated Rate	$72.18
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	$43.31
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 Beech St/Commercial/PHCS	$72.18

COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]

Facility

$96.24

Service Code	CPT J0834
Hospital Charge Code	1754264
Hospital Revenue Code	636
Min. Negotiated Rate	$52.93
Max. Negotiated Rate	$76.99
Rate for Payer: Cash Price	$43.31
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$72.18

COVID VAC 2023-24 (12YR AND UP)(ANDUSOMERAN)(PF) 50 MCG/0.5 ML IM SUSP [239502]

Facility

$307.20

Service Code	CPT 91322
Hospital Charge Code	NDG239502
Hospital Revenue Code	636
Min. Negotiated Rate	$168.96
Max. Negotiated Rate	$245.76
Rate for Payer: Cash Price	$138.24
Rate for Payer: Cigna of CA HMO/PPO	$245.76
Rate for Payer: Health Smart Auto/Commercial	$184.32
Rate for Payer: LLUH Dept of Risk Management WC	$168.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$230.40

COVID VAC 2023-24 (12YR AND UP)(ANDUSOMERAN)(PF) 50 MCG/0.5 ML IM SUSP [239502]

Facility

$307.20

Service Code	CPT 91322
Hospital Charge Code	NDG239502
Hospital Revenue Code	636
Min. Negotiated Rate	$168.96
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$184.32
Rate for Payer: Aetna of CA Government/Medicare	$184.32
Rate for Payer: Cash Price	$138.24
Rate for Payer: Health Smart Auto/Commercial	$184.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$184.32
Rate for Payer: LLUH Dept of Risk Management WC	$168.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$230.40

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

Facility

$294.35

Service Code	NDC 0078-0883-61
Hospital Charge Code	NDG225907
Hospital Revenue Code	636
Min. Negotiated Rate	$161.89
Max. Negotiated Rate	$220.76
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	$132.46
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 Beech St/Commercial/PHCS	$220.76

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

Facility

$294.35

Service Code	NDC 0078-0883-61
Hospital Charge Code	NDG225907
Hospital Revenue Code	636
Min. Negotiated Rate	$161.89
Max. Negotiated Rate	$235.48
Rate for Payer: Cash Price	$132.46
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$220.76

CRIZOTINIB 250 MG CAPSULE [153216]

Facility

$423.16

Service Code	NDC 0069-8140-20
Hospital Charge Code	1712554
Hospital Revenue Code	259
Min. Negotiated Rate	$232.74
Max. Negotiated Rate	$338.53
Rate for Payer: Cash Price	$190.42
Rate for Payer: Cigna of CA HMO/PPO	$338.53
Rate for Payer: Health Smart Auto/Commercial	$253.90
Rate for Payer: LLUH Dept of Risk Management WC	$232.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$317.37

CRIZOTINIB 250 MG CAPSULE [153216]

Facility

$423.16

Service Code	NDC 0069-8140-20
Hospital Charge Code	1712554
Hospital Revenue Code	259
Min. Negotiated Rate	$232.74
Max. Negotiated Rate	$317.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$253.90
Rate for Payer: Aetna of CA Government/Medicare	$253.90
Rate for Payer: Cash Price	$190.42
Rate for Payer: Health Smart Auto/Commercial	$253.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$253.90
Rate for Payer: LLUH Dept of Risk Management WC	$232.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$317.37

Know your out-of-pocket cost for care.

All Charges