Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.36

Service Code	NDC 60687-377-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.05

Service Code	NDC 65862-676-01
Hospital Charge Code	901700029
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
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 Commercial	$0.04

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.05

Service Code	NDC 65862-676-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.04

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.36

Service Code	NDC 60687-377-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.06

Service Code	NDC 0228-2029-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.06

Service Code	NDC 0228-2029-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.05

Service Code	NDC 59762-3720-1
Hospital Charge Code	901700029
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
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 Commercial	$0.04

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.44

Service Code	NDC 60687-388-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.44

Service Code	NDC 60687-388-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.44

Service Code	NDC 60687-388-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.05

Service Code	NDC 59762-3720-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.04

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.44

Service Code	NDC 60687-388-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.06

Service Code	NDC 59762-3721-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.05

Service Code	NDC 65862-678-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.04

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.05

Service Code	NDC 65862-678-01
Hospital Charge Code	901700029
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
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 Commercial	$0.04

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.06

Service Code	NDC 59762-3721-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR NEURO IR [40823708]

Facility

$183.67

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$101.02
Max. Negotiated Rate	$146.94
Rate for Payer: Cash Price	$101.02
Rate for Payer: Cash Price	$122.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Commercial	$137.75
Rate for Payer: Multiplan Commercial	$166.65

ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR NEURO IR [40823708]

Facility

$183.67

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$101.02
Max. Negotiated Rate	$146.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.32
Rate for Payer: Aetna of CA Government/Medicare	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$133.32
Rate for Payer: Cash Price	$101.02
Rate for Payer: Cash Price	$122.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.32
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Commercial	$137.75
Rate for Payer: Multiplan Commercial	$166.65

ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]

Facility

$222.20

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$122.21
Max. Negotiated Rate	$177.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$133.32
Rate for Payer: Aetna of CA Government/Medicare	$110.20
Rate for Payer: Cash Price	$122.21
Rate for Payer: Cash Price	$101.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.20
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: Multiplan Commercial	$166.65
Rate for Payer: Multiplan Commercial	$137.75

ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]

Facility

$183.67

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$101.02
Max. Negotiated Rate	$146.94
Rate for Payer: Cash Price	$101.02
Rate for Payer: Cash Price	$122.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: Multiplan Commercial	$137.75
Rate for Payer: Multiplan Commercial	$166.65

ALTEPLASE (CATHFLO) SYRINGE 2 MG/2 ML FOR NEBULIZATION [4081953]

Facility

$222.20

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$122.21
Max. Negotiated Rate	$177.76
Rate for Payer: Cash Price	$122.21
Rate for Payer: Cash Price	$101.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Commercial	$137.75
Rate for Payer: Multiplan Commercial	$166.65

ALTEPLASE (CATHFLO) SYRINGE 2 MG/2 ML FOR NEBULIZATION [4081953]

Facility

$222.20

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$122.21
Max. Negotiated Rate	$177.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$133.32
Rate for Payer: Aetna of CA Government/Medicare	$110.20
Rate for Payer: Cash Price	$122.21
Rate for Payer: Cash Price	$101.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.32
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Commercial	$166.65
Rate for Payer: Multiplan Commercial	$137.75

ALTEPLASE INTRAVENTRICULAR 2 MG/2 ML SYRINGE [40820125]

Facility

$183.67

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$101.02
Max. Negotiated Rate	$146.94
Rate for Payer: Cash Price	$101.02
Rate for Payer: Cash Price	$122.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: Multiplan Commercial	$166.65
Rate for Payer: Multiplan Commercial	$137.75

ALTEPLASE INTRAVENTRICULAR 2 MG/2 ML SYRINGE [40820125]

Facility

$222.20

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$122.21
Max. Negotiated Rate	$177.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$133.32
Rate for Payer: Aetna of CA Government/Medicare	$110.20
Rate for Payer: Cash Price	$101.02
Rate for Payer: Cash Price	$122.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.76
Rate for Payer: Health Smart Auto/Commercial	$133.32
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.20
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: LLUH Dept of Risk Management WC	$122.21
Rate for Payer: Multiplan Commercial	$137.75
Rate for Payer: Multiplan Commercial	$166.65

ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]

Facility

$0.02

Service Code	NDC 0536-0091-85
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

Know your out-of-pocket cost for care.

All Charges