Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.06

Service Code	NDC 0228-2027-10
Hospital Charge Code	1730011
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

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.04

Service Code	NDC 51991-704-01
Hospital Charge Code	1730011
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.02
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	$0.03

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.05

Service Code	NDC 65862-676-01
Hospital Charge Code	1730011
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	$0.02
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 Beech St/Commercial/PHCS	$0.04

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.04

Service Code	NDC 59762-3719-1
Hospital Charge Code	1730011
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.02
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	$0.03

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.06

Service Code	NDC 0228-2027-10
Hospital Charge Code	1730011
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: 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 Beech St/Commercial/PHCS	$0.05

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.05

Service Code	NDC 65862-676-01
Hospital Charge Code	1730011
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

ALPRAZOLAM 0.25 MG TABLET [324]

Facility

$0.04

Service Code	NDC 51991-704-01
Hospital Charge Code	1730011
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.06

Service Code	NDC 0228-2029-10
Hospital Charge Code	1730012
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

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.05

Service Code	NDC 59762-3720-1
Hospital Charge Code	1730012
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

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.05

Service Code	NDC 65862-677-01
Hospital Charge Code	1730012
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

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.06

Service Code	NDC 0228-2029-10
Hospital Charge Code	1730012
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: 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 Beech St/Commercial/PHCS	$0.05

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.05

Service Code	NDC 65862-677-01
Hospital Charge Code	1730012
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	$0.02
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 Beech St/Commercial/PHCS	$0.04

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

$0.05

Service Code	NDC 59762-3720-1
Hospital Charge Code	1730012
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	$0.02
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 Beech St/Commercial/PHCS	$0.04

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.06

Service Code	NDC 59762-3721-1
Hospital Charge Code	1730117
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

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.05

Service Code	NDC 65862-678-01
Hospital Charge Code	1730117
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	$0.02
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 Beech St/Commercial/PHCS	$0.04

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.05

Service Code	NDC 65862-678-01
Hospital Charge Code	1730117
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

ALPRAZOLAM 1 MG TABLET [326]

Facility

$0.06

Service Code	NDC 59762-3721-1
Hospital Charge Code	1730117
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: 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 Beech St/Commercial/PHCS	$0.05

ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]

Facility

$10,560.43

Service Code	CPT J2997
Hospital Charge Code	1720787
Hospital Revenue Code	636
Min. Negotiated Rate	$5,808.24
Max. Negotiated Rate	$8,448.34
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Cigna of CA HMO/PPO	$8,448.34
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,920.32

ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]

Facility

$10,560.43

Service Code	CPT J2997
Hospital Charge Code	1720787
Hospital Revenue Code	636
Min. Negotiated Rate	$5,808.24
Max. Negotiated Rate	$7,920.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6,336.26
Rate for Payer: Aetna of CA Government/Medicare	$6,336.26
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,920.32

ALTEPLASE 100 MG INTRAVENOUS SOLUTION (ACUTE THROMBOEMBOLIC STROKE) [4081495]

Facility

$10,560.43

Service Code	CPT J2997
Hospital Revenue Code	636
Min. Negotiated Rate	$5,808.24
Max. Negotiated Rate	$7,920.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6,336.26
Rate for Payer: Aetna of CA Government/Medicare	$6,336.26
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,920.32

ALTEPLASE 100 MG INTRAVENOUS SOLUTION (ACUTE THROMBOEMBOLIC STROKE) [4081495]

Facility

$10,560.43

Service Code	CPT J2997
Hospital Revenue Code	636
Min. Negotiated Rate	$5,808.24
Max. Negotiated Rate	$8,448.34
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Cigna of CA HMO/PPO	$8,448.34
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,920.32

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

Facility

$201.54

Service Code	CPT J2997
Hospital Charge Code	ERX40823708
Hospital Revenue Code	636
Min. Negotiated Rate	$110.85
Max. Negotiated Rate	$151.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$120.92
Rate for Payer: Cash Price	$90.69
Rate for Payer: Cash Price	$82.65
Rate for Payer: Health Smart Auto/Commercial	$120.92
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.92
Rate for Payer: LLUH Dept of Risk Management WC	$110.85
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$151.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$137.75

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

Facility

$183.67

Service Code	CPT J2997
Hospital Charge Code	ERX40823708
Hospital Revenue Code	636
Min. Negotiated Rate	$101.02
Max. Negotiated Rate	$146.94
Rate for Payer: Cash Price	$82.65
Rate for Payer: Cash Price	$90.69
Rate for Payer: Cigna of CA HMO/PPO	$161.23
Rate for Payer: Cigna of CA HMO/PPO	$146.94
Rate for Payer: Health Smart Auto/Commercial	$120.92
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: LLUH Dept of Risk Management WC	$110.85
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$151.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$137.75

ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]

Facility

$201.54

Service Code	CPT J2997
Hospital Charge Code	1720932
Hospital Revenue Code	636
Min. Negotiated Rate	$110.85
Max. Negotiated Rate	$151.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.20
Rate for Payer: Aetna of CA Government/Medicare	$120.92
Rate for Payer: Aetna of CA Government/Medicare	$110.20
Rate for Payer: Cash Price	$82.65
Rate for Payer: Cash Price	$90.69
Rate for Payer: Health Smart Auto/Commercial	$120.92
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.92
Rate for Payer: LLUH Dept of Risk Management WC	$110.85
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$151.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$137.75

ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]

Facility

$183.67

Service Code	CPT J2997
Hospital Charge Code	1720932
Hospital Revenue Code	636
Min. Negotiated Rate	$101.02
Max. Negotiated Rate	$146.94
Rate for Payer: Cash Price	$82.65
Rate for Payer: Cash Price	$90.69
Rate for Payer: Cigna of CA HMO/PPO	$161.23
Rate for Payer: Cigna of CA HMO/PPO	$146.94
Rate for Payer: Health Smart Auto/Commercial	$120.92
Rate for Payer: Health Smart Auto/Commercial	$110.20
Rate for Payer: LLUH Dept of Risk Management WC	$101.02
Rate for Payer: LLUH Dept of Risk Management WC	$110.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$137.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$151.16

Know your out-of-pocket cost for care.

All Charges