Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CROMOLYN 20 MG/2 ML SOLUTION FOR NEBULIZATION [9690]

Facility

$10.85

Service Code	NDC 69784-205-60
Hospital Charge Code	1781097
Hospital Revenue Code	259
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$8.68
Rate for Payer: Cash Price	$4.88
Rate for Payer: Cigna of CA HMO/PPO	$8.68
Rate for Payer: Health Smart Auto/Commercial	$6.51
Rate for Payer: LLUH Dept of Risk Management WC	$5.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.14

CROMOLYN 20 MG/2 ML SOLUTION FOR NEBULIZATION [9690]

Facility

$10.85

Service Code	NDC 69784-205-60
Hospital Charge Code	1781097
Hospital Revenue Code	259
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$8.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.51
Rate for Payer: Aetna of CA Government/Medicare	$6.51
Rate for Payer: Cash Price	$4.88
Rate for Payer: Health Smart Auto/Commercial	$6.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.51
Rate for Payer: LLUH Dept of Risk Management WC	$5.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.14

CROMOLYN 4 % EYE DROPS [9691]

Facility

$2.70

Service Code	NDC 61314-237-10
Hospital Charge Code	1744076
Hospital Revenue Code	259
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.16
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.02

CROMOLYN 4 % EYE DROPS [9691]

Facility

$2.70

Service Code	NDC 61314-237-10
Hospital Charge Code	1744076
Hospital Revenue Code	259
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.62
Rate for Payer: Aetna of CA Government/Medicare	$1.62
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.02

CROMOLYN 4 % EYE DROPS [9691]

Facility

$2.74

Service Code	NDC 17478-291-11
Hospital Charge Code	1744076
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.19
Rate for Payer: Cash Price	$1.23
Rate for Payer: Cigna of CA HMO/PPO	$2.19
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.06

CROMOLYN 4 % EYE DROPS [9691]

Facility

$2.74

Service Code	NDC 17478-291-11
Hospital Charge Code	1744076
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.64
Rate for Payer: Aetna of CA Government/Medicare	$1.64
Rate for Payer: Cash Price	$1.23
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.06

CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION [29313]

Facility

$3,837.60

Service Code	CPT J0840
Hospital Charge Code	1759986
Hospital Revenue Code	636
Min. Negotiated Rate	$2,110.68
Max. Negotiated Rate	$3,070.08
Rate for Payer: Cash Price	$1,726.92
Rate for Payer: Cigna of CA HMO/PPO	$3,070.08
Rate for Payer: Health Smart Auto/Commercial	$2,302.56
Rate for Payer: LLUH Dept of Risk Management WC	$2,110.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,878.20

CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION [29313]

Facility

$3,837.60

Service Code	CPT J0840
Hospital Charge Code	1759986
Hospital Revenue Code	636
Min. Negotiated Rate	$2,110.68
Max. Negotiated Rate	$2,878.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,302.56
Rate for Payer: Aetna of CA Government/Medicare	$2,302.56
Rate for Payer: Cash Price	$1,726.92
Rate for Payer: Health Smart Auto/Commercial	$2,302.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,302.56
Rate for Payer: LLUH Dept of Risk Management WC	$2,110.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,878.20

CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]

Facility

$3.15

Service Code	NDC 0409-4092-01
Hospital Charge Code	NDG110358
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.89
Rate for Payer: Aetna of CA Government/Medicare	$1.89
Rate for Payer: Cash Price	$1.42
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.36

CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]

Facility

$3.15

Service Code	NDC 0409-4092-11
Hospital Charge Code	NDG110358
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Cash Price	$1.42
Rate for Payer: Cigna of CA HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.36

CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]

Facility

$2.60

Service Code	NDC 9994-0804-25
Hospital Charge Code	ERX110358
Hospital Revenue Code	250
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

CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]

Facility

$2.60

Service Code	NDC 9994-0804-25
Hospital Charge Code	ERX110358
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cigna of CA HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Cash Price	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.95

CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]

Facility

$3.15

Service Code	NDC 0409-4092-11
Hospital Charge Code	NDG110358
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.36
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.89
Rate for Payer: Aetna of CA Government/Medicare	$1.89
Rate for Payer: Cash Price	$1.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.36

CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]

Facility

$3.15

Service Code	NDC 0409-4092-01
Hospital Charge Code	NDG110358
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Cash Price	$1.42
Rate for Payer: Cigna of CA HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.36

CVL-NICARDIPINE 20 MG/200 ML PREMIX FOR INTRA-ART/INTRA-CORONARY [4081031]

Facility

$0.61

Service Code	NDC 10122-313-10
Hospital Charge Code	1771308
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.49
Rate for Payer: Cash Price	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.46

CVL-NICARDIPINE 20 MG/200 ML PREMIX FOR INTRA-ART/INTRA-CORONARY [4081031]

Facility

$0.61

Service Code	NDC 10122-313-10
Hospital Charge Code	1771308
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.46

CVL-NITROGLYCERIN 50MG/500ML NS FOR IA/IC BOLUS [4080932]

Facility

$8.75

Service Code	NDC 9994-0809-32
Hospital Charge Code	NDG4080932
Hospital Revenue Code	250
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$7.00
Rate for Payer: Cash Price	$3.94
Rate for Payer: Cigna of CA HMO/PPO	$7.00
Rate for Payer: Health Smart Auto/Commercial	$5.25
Rate for Payer: LLUH Dept of Risk Management WC	$4.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.56

CVL-NITROGLYCERIN 50MG/500ML NS FOR IA/IC BOLUS [4080932]

Facility

$8.75

Service Code	NDC 9994-0809-32
Hospital Charge Code	NDG4080932
Hospital Revenue Code	250
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$6.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.25
Rate for Payer: Aetna of CA Government/Medicare	$5.25
Rate for Payer: Cash Price	$3.94
Rate for Payer: Health Smart Auto/Commercial	$5.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.25
Rate for Payer: LLUH Dept of Risk Management WC	$4.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.56

CVL-VERAPAMIL 5MG/50ML NS FOR IA/IC BOLUS [4080934]

Facility

$0.81

Service Code	NDC 9994-0809-34
Hospital Charge Code	NDC4080934
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

CVL-VERAPAMIL 5MG/50ML NS FOR IA/IC BOLUS [4080934]

Facility

$0.81

Service Code	NDC 9994-0809-34
Hospital Charge Code	NDC4080934
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]

Facility

$8.39

Service Code	CPT J3420
Hospital Charge Code	1720402
Hospital Revenue Code	636
Min. Negotiated Rate	$4.61
Max. Negotiated Rate	$6.71
Rate for Payer: Cash Price	$3.78
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cigna of CA HMO/PPO	$6.64
Rate for Payer: Cigna of CA HMO/PPO	$6.71
Rate for Payer: Health Smart Auto/Commercial	$4.98
Rate for Payer: Health Smart Auto/Commercial	$5.03
Rate for Payer: LLUH Dept of Risk Management WC	$4.61
Rate for Payer: LLUH Dept of Risk Management WC	$4.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.22

CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]

Facility

$8.39

Service Code	CPT J3420
Hospital Charge Code	1720402
Hospital Revenue Code	636
Min. Negotiated Rate	$4.61
Max. Negotiated Rate	$6.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.98
Rate for Payer: Aetna of CA Government/Medicare	$5.03
Rate for Payer: Aetna of CA Government/Medicare	$4.98
Rate for Payer: Cash Price	$3.78
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Smart Auto/Commercial	$5.03
Rate for Payer: Health Smart Auto/Commercial	$4.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.98
Rate for Payer: LLUH Dept of Risk Management WC	$4.61
Rate for Payer: LLUH Dept of Risk Management WC	$4.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.22

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [2009]

Facility

$0.25

Service Code	NDC 5026885515
Hospital Charge Code	1712196
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

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [2009]

Facility

$0.25

Service Code	NDC 5026885511
Hospital Charge Code	1712196
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

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [2009]

Facility

$0.03

Service Code	NDC 1013565201
Hospital Charge Code	1712196
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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	$0.02

Know your out-of-pocket cost for care.

All Charges