Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CYCLOBENZAPRINE 5 MG TABLET [35184]

Facility

$0.06

Service Code	NDC 69097-845-07
Hospital Charge Code	1712380
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

CYCLOBENZAPRINE 5 MG TABLET [35184]

Facility

$0.05

Service Code	NDC 0378-0771-01
Hospital Charge Code	1712380
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

CYCLOBENZAPRINE 5 MG TABLET [35184]

Facility

$0.60

Service Code	NDC 68084-753-25
Hospital Charge Code	1712380
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

CYCLOBENZAPRINE 5 MG TABLET [35184]

Facility

$0.82

Service Code	NDC 50268-190-11
Hospital Charge Code	1712380
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.62
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	$0.37
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	$0.62

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

$2.24

Service Code	NDC 61314-396-03
Hospital Charge Code	1740075
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna of CA HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.68

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

$2.24

Service Code	NDC 61314-396-03
Hospital Charge Code	1740075
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.68

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

$7.17

Service Code	NDC 61314-396-01
Hospital Charge Code	1740068
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.30
Rate for Payer: Aetna of CA Government/Medicare	$4.30
Rate for Payer: Cash Price	$3.23
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.38

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

$7.17

Service Code	NDC 61314-396-01
Hospital Charge Code	1740068
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.74
Rate for Payer: Cash Price	$3.23
Rate for Payer: Cigna of CA HMO/PPO	$5.74
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.38

CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]

Facility

$19.96

Service Code	NDC 0065-0359-02
Hospital Charge Code	1740343
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$15.97
Rate for Payer: Cash Price	$8.98
Rate for Payer: Cigna of CA HMO/PPO	$15.97
Rate for Payer: Health Smart Auto/Commercial	$11.98
Rate for Payer: LLUH Dept of Risk Management WC	$10.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.97

CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]

Facility

$19.96

Service Code	NDC 0065-0359-02
Hospital Charge Code	1740343
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$14.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.98
Rate for Payer: Aetna of CA Government/Medicare	$11.98
Rate for Payer: Cash Price	$8.98
Rate for Payer: Health Smart Auto/Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.98
Rate for Payer: LLUH Dept of Risk Management WC	$10.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.97

CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]

Facility

$879.00

Service Code	CPT J9070
Hospital Charge Code	1755736
Hospital Revenue Code	636
Min. Negotiated Rate	$483.45
Max. Negotiated Rate	$659.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$527.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$403.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$474.66
Rate for Payer: Aetna of CA Government/Medicare	$474.66
Rate for Payer: Aetna of CA Government/Medicare	$403.46
Rate for Payer: Aetna of CA Government/Medicare	$527.40
Rate for Payer: Cash Price	$302.59
Rate for Payer: Cash Price	$395.55
Rate for Payer: Cash Price	$356.00
Rate for Payer: Health Smart Auto/Commercial	$527.40
Rate for Payer: Health Smart Auto/Commercial	$474.66
Rate for Payer: Health Smart Auto/Commercial	$403.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$403.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$474.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$527.40
Rate for Payer: LLUH Dept of Risk Management WC	$483.45
Rate for Payer: LLUH Dept of Risk Management WC	$435.10
Rate for Payer: LLUH Dept of Risk Management WC	$369.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$659.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$504.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$593.32

CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]

Facility

$879.00

Service Code	CPT J9070
Hospital Charge Code	1755736
Hospital Revenue Code	636
Min. Negotiated Rate	$483.45
Max. Negotiated Rate	$703.20
Rate for Payer: Cash Price	$395.55
Rate for Payer: Cash Price	$302.59
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cigna of CA HMO/PPO	$703.20
Rate for Payer: Cigna of CA HMO/PPO	$537.94
Rate for Payer: Cigna of CA HMO/PPO	$632.88
Rate for Payer: Health Smart Auto/Commercial	$527.40
Rate for Payer: Health Smart Auto/Commercial	$474.66
Rate for Payer: Health Smart Auto/Commercial	$403.46
Rate for Payer: LLUH Dept of Risk Management WC	$435.10
Rate for Payer: LLUH Dept of Risk Management WC	$369.84
Rate for Payer: LLUH Dept of Risk Management WC	$483.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$593.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$504.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$659.25

CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]

Facility

$3.60

Service Code	CPT J8530
Hospital Charge Code	ERX206105
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.42
Rate for Payer: Aetna of CA Government/Medicare	$2.42
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$1.82
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.03

CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]

Facility

$3.60

Service Code	CPT J8530
Hospital Charge Code	ERX206105
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cash Price	$1.82
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Cigna of CA HMO/PPO	$3.23
Rate for Payer: Cigna of CA HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]

Facility

$1,758.00

Service Code	CPT J9070
Hospital Charge Code	1755757
Hospital Revenue Code	636
Min. Negotiated Rate	$966.90
Max. Negotiated Rate	$1,318.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,054.80
Rate for Payer: Aetna of CA Government/Medicare	$1,054.80
Rate for Payer: Cash Price	$791.10
Rate for Payer: Health Smart Auto/Commercial	$1,054.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,054.80
Rate for Payer: LLUH Dept of Risk Management WC	$966.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,318.50

CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]

Facility

$1,758.00

Service Code	CPT J9070
Hospital Charge Code	1755757
Hospital Revenue Code	636
Min. Negotiated Rate	$966.90
Max. Negotiated Rate	$1,406.40
Rate for Payer: Cash Price	$791.10
Rate for Payer: Cigna of CA HMO/PPO	$1,406.40
Rate for Payer: Health Smart Auto/Commercial	$1,054.80
Rate for Payer: LLUH Dept of Risk Management WC	$966.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,318.50

CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]

Facility

$222.00

Service Code	CPT J9070
Hospital Charge Code	ERX38271
Hospital Revenue Code	636
Min. Negotiated Rate	$122.10
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$201.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$263.70
Rate for Payer: Aetna of CA Government/Medicare	$263.70
Rate for Payer: Aetna of CA Government/Medicare	$133.20
Rate for Payer: Aetna of CA Government/Medicare	$201.74
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$197.78
Rate for Payer: Cash Price	$151.30
Rate for Payer: Health Smart Auto/Commercial	$133.20
Rate for Payer: Health Smart Auto/Commercial	$263.70
Rate for Payer: Health Smart Auto/Commercial	$201.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$263.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$201.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.20
Rate for Payer: LLUH Dept of Risk Management WC	$184.93
Rate for Payer: LLUH Dept of Risk Management WC	$241.72
Rate for Payer: LLUH Dept of Risk Management WC	$122.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$252.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$329.62

CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]

Facility

$336.23

Service Code	CPT J9070
Hospital Charge Code	ERX38271
Hospital Revenue Code	636
Min. Negotiated Rate	$184.93
Max. Negotiated Rate	$268.98
Rate for Payer: Cash Price	$151.30
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$197.78
Rate for Payer: Cigna of CA HMO/PPO	$351.60
Rate for Payer: Cigna of CA HMO/PPO	$177.60
Rate for Payer: Cigna of CA HMO/PPO	$268.98
Rate for Payer: Health Smart Auto/Commercial	$133.20
Rate for Payer: Health Smart Auto/Commercial	$201.74
Rate for Payer: Health Smart Auto/Commercial	$263.70
Rate for Payer: LLUH Dept of Risk Management WC	$184.93
Rate for Payer: LLUH Dept of Risk Management WC	$122.10
Rate for Payer: LLUH Dept of Risk Management WC	$241.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$252.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$329.62

CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]

Facility

$5.30

Service Code	NDC 9994-0802-61
Hospital Charge Code	1715018
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.24
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]

Facility

$5.30

Service Code	NDC 9994-0802-61
Hospital Charge Code	1715018
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.98
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	$2.39
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 Beech St/Commercial/PHCS	$3.98

CYCLOSPORINE 0.05 % EYE DROPS [216389]

Facility

$140.87

Service Code	NDC 0023-5301-05
Hospital Charge Code	NDG216389
Hospital Revenue Code	259
Min. Negotiated Rate	$77.48
Max. Negotiated Rate	$105.65
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	$63.39
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	$77.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$105.65

CYCLOSPORINE 0.05 % EYE DROPS [216389]

Facility

$140.87

Service Code	NDC 0023-5301-05
Hospital Charge Code	NDG216389
Hospital Revenue Code	259
Min. Negotiated Rate	$77.48
Max. Negotiated Rate	$112.70
Rate for Payer: Cash Price	$63.39
Rate for Payer: Cigna of CA HMO/PPO	$112.70
Rate for Payer: Health Smart Auto/Commercial	$84.52
Rate for Payer: LLUH Dept of Risk Management WC	$77.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$105.65

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$5.60

Service Code	NDC 60505-6202-1
Hospital Charge Code	1740336
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$4.20

CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [35209]

Facility

$5.60

Service Code	NDC 60505-6202-1
Hospital Charge Code	1740336
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.20
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	$2.52
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 Beech St/Commercial/PHCS	$4.20

CYCLOSPORINE 100 MG CAPSULE [9706]

Facility

$20.24

Service Code	CPT J7502
Hospital Charge Code	1711475
Hospital Revenue Code	636
Min. Negotiated Rate	$11.13
Max. Negotiated Rate	$16.19
Rate for Payer: Cash Price	$9.11
Rate for Payer: Cash Price	$6.63
Rate for Payer: Cash Price	$9.12
Rate for Payer: Cigna of CA HMO/PPO	$16.19
Rate for Payer: Cigna of CA HMO/PPO	$16.22
Rate for Payer: Cigna of CA HMO/PPO	$11.79
Rate for Payer: Health Smart Auto/Commercial	$12.14
Rate for Payer: Health Smart Auto/Commercial	$8.84
Rate for Payer: Health Smart Auto/Commercial	$12.16
Rate for Payer: LLUH Dept of Risk Management WC	$11.13
Rate for Payer: LLUH Dept of Risk Management WC	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.20

Know your out-of-pocket cost for care.

All Charges