Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

CYCLOSPORINE 100 MG/ML ORAL SOLUTION [9708]

Facility

$19.66

Service Code	CPT J7502
Hospital Charge Code	1719136
Hospital Revenue Code	636
Min. Negotiated Rate	$10.81
Max. Negotiated Rate	$15.73
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cigna of CA HMO/PPO	$15.73
Rate for Payer: Health Smart Auto/Commercial	$11.80
Rate for Payer: LLUH Dept of Risk Management WC	$10.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.74

CYCLOSPORINE 100 MG/ML ORAL SOLUTION [9708]

Facility

$19.66

Service Code	CPT J7502
Hospital Charge Code	1719136
Hospital Revenue Code	636
Min. Negotiated Rate	$10.81
Max. Negotiated Rate	$14.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.80
Rate for Payer: Aetna of CA Government/Medicare	$11.80
Rate for Payer: Cash Price	$8.85
Rate for Payer: Health Smart Auto/Commercial	$11.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.80
Rate for Payer: LLUH Dept of Risk Management WC	$10.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.74

CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]

Facility

$15.78

Service Code	CPT J7516
Hospital Charge Code	NDG9705
Hospital Revenue Code	636
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$7.10
Rate for Payer: Cash Price	$4.23
Rate for Payer: Cigna of CA HMO/PPO	$12.62
Rate for Payer: Cigna of CA HMO/PPO	$7.51
Rate for Payer: Health Smart Auto/Commercial	$5.63
Rate for Payer: Health Smart Auto/Commercial	$9.47
Rate for Payer: LLUH Dept of Risk Management WC	$5.16
Rate for Payer: LLUH Dept of Risk Management WC	$8.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.84

CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]

Facility

$9.39

Service Code	CPT J7516
Hospital Charge Code	NDG9705
Hospital Revenue Code	636
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$7.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.47
Rate for Payer: Aetna of CA Government/Medicare	$5.63
Rate for Payer: Aetna of CA Government/Medicare	$9.47
Rate for Payer: Cash Price	$4.23
Rate for Payer: Cash Price	$7.10
Rate for Payer: Health Smart Auto/Commercial	$5.63
Rate for Payer: Health Smart Auto/Commercial	$9.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.47
Rate for Payer: LLUH Dept of Risk Management WC	$5.16
Rate for Payer: LLUH Dept of Risk Management WC	$8.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.84

CYCLOSPORINE 25 MG CAPSULE [9707]

Facility

$3.69

Service Code	CPT J7515
Hospital Charge Code	1711480
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$3.04
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$2.21
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cash Price	$2.28
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Smart Auto/Commercial	$3.04
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: LLUH Dept of Risk Management WC	$2.79
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.80

CYCLOSPORINE 25 MG CAPSULE [9707]

Facility

$5.12

Service Code	CPT J7515
Hospital Charge Code	1711480
Hospital Revenue Code	636
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cash Price	$2.28
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cigna of CA HMO/PPO	$4.06
Rate for Payer: Cigna of CA HMO/PPO	$2.95
Rate for Payer: Cigna of CA HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: Health Smart Auto/Commercial	$3.04
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.80

CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]

Facility

$5.28

Service Code	CPT J7502
Hospital Charge Code	1712179
Hospital Revenue Code	636
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$4.22
Rate for Payer: Cash Price	$2.38
Rate for Payer: Cash Price	$3.78
Rate for Payer: Cigna of CA HMO/PPO	$6.72
Rate for Payer: Cigna of CA HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: LLUH Dept of Risk Management WC	$4.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.30

CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]

Facility

$5.28

Service Code	CPT J7502
Hospital Charge Code	1712179
Hospital Revenue Code	636
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$3.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.04
Rate for Payer: Aetna of CA Government/Medicare	$3.17
Rate for Payer: Aetna of CA Government/Medicare	$5.04
Rate for Payer: Cash Price	$2.38
Rate for Payer: Cash Price	$3.78
Rate for Payer: Health Smart Auto/Commercial	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.04
Rate for Payer: LLUH Dept of Risk Management WC	$4.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.30

CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]

Facility

$13.59

Service Code	CPT J7502
Hospital Charge Code	NDG28844
Hospital Revenue Code	636
Min. Negotiated Rate	$7.47
Max. Negotiated Rate	$10.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.69
Rate for Payer: Aetna of CA Government/Medicare	$8.15
Rate for Payer: Aetna of CA Government/Medicare	$3.40
Rate for Payer: Aetna of CA Government/Medicare	$5.69
Rate for Payer: Cash Price	$2.55
Rate for Payer: Cash Price	$6.12
Rate for Payer: Cash Price	$4.27
Rate for Payer: Health Smart Auto/Commercial	$8.15
Rate for Payer: Health Smart Auto/Commercial	$3.40
Rate for Payer: Health Smart Auto/Commercial	$5.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.15
Rate for Payer: LLUH Dept of Risk Management WC	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$5.22
Rate for Payer: LLUH Dept of Risk Management WC	$7.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.24

CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]

Facility

$9.49

Service Code	CPT J7502
Hospital Charge Code	NDG28844
Hospital Revenue Code	636
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$7.59
Rate for Payer: Cash Price	$4.27
Rate for Payer: Cash Price	$2.55
Rate for Payer: Cash Price	$6.12
Rate for Payer: Cigna of CA HMO/PPO	$4.53
Rate for Payer: Cigna of CA HMO/PPO	$7.59
Rate for Payer: Cigna of CA HMO/PPO	$10.87
Rate for Payer: Health Smart Auto/Commercial	$3.40
Rate for Payer: Health Smart Auto/Commercial	$5.69
Rate for Payer: Health Smart Auto/Commercial	$8.15
Rate for Payer: LLUH Dept of Risk Management WC	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$7.47
Rate for Payer: LLUH Dept of Risk Management WC	$5.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.12

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$1.32

Service Code	CPT J7515
Hospital Charge Code	1712180
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.99

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$1.32

Service Code	CPT J7515
Hospital Charge Code	1712180
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.99

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.11

Service Code	NDC 50742-190-01
Hospital Charge Code	1710485
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-15
Hospital Charge Code	1710485
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-11
Hospital Charge Code	1710485
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.59

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-11
Hospital Charge Code	1710485
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.11

Service Code	NDC 50742-190-01
Hospital Charge Code	1710485
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$0.78

Service Code	NDC 50268-189-15
Hospital Charge Code	1710485
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.59

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

Facility

$11.36

Service Code	NDC 51754-1007-1
Hospital Charge Code	NDG4294B
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$9.09
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$8.52

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

Facility

$11.36

Service Code	NDC 51754-1007-1
Hospital Charge Code	NDG4294B
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$8.52
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	$5.11
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 Beech St/Commercial/PHCS	$8.52

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

Facility

$11.36

Service Code	NDC 51754-1007-3
Hospital Charge Code	NDG4294B
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$8.52
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	$5.11
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 Beech St/Commercial/PHCS	$8.52

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

Facility

$11.36

Service Code	NDC 51754-1007-3
Hospital Charge Code	NDG4294B
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$9.09
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$8.52

CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [120408]

Facility

$1.52

Service Code	CPT J9100
Hospital Charge Code	NDG120408
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [120408]

Facility

$1.52

Service Code	CPT J9100
Hospital Charge Code	NDG120408
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

Know your out-of-pocket cost for care.

All Charges