Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]

Facility

$2.00

Service Code	NDC 51672-1303-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]

Facility

$260.92

Service Code	HCPCS J1299
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$143.51
Max. Negotiated Rate	$208.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$156.55
Rate for Payer: Aetna of CA Government/Medicare	$156.55
Rate for Payer: Cash Price	$143.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$208.74
Rate for Payer: Health Smart Auto/Commercial	$156.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$156.55
Rate for Payer: LLUH Dept of Risk Management WC	$143.51
Rate for Payer: Multiplan Commercial	$195.69

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]

Facility

$260.92

Service Code	HCPCS J1299
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$143.51
Max. Negotiated Rate	$208.74
Rate for Payer: Cash Price	$143.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$208.74
Rate for Payer: Health Smart Auto/Commercial	$156.55
Rate for Payer: LLUH Dept of Risk Management WC	$143.51
Rate for Payer: Multiplan Commercial	$195.69

EDETATE DISODIUM 3 % EYE DROPS [222529]

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$16.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

EDETATE DISODIUM 3 % EYE DROPS [222529]

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$16.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.92
Rate for Payer: Aetna of CA Government/Medicare	$1.92
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.56
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Commercial	$2.40

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.56
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Commercial	$2.40

ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]

Facility

$0.02

Service Code	NDC 0338-0221-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]

Facility

$0.02

Service Code	NDC 0338-0221-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

ELECTROLYTE-S IV BOLUS [192101]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

ELECTROLYTE-S IV BOLUS [192101]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]

Facility

$0.01

Service Code	NDC 0264-7707-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]

Facility

$0.01

Service Code	NDC 0264-7707-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

ELETRIPTAN 20 MG TABLET [34683]

Facility

$96.92

Service Code	NDC 0049-2330-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$53.31
Max. Negotiated Rate	$77.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$58.15
Rate for Payer: Aetna of CA Government/Medicare	$58.15
Rate for Payer: Cash Price	$53.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$77.54
Rate for Payer: Health Smart Auto/Commercial	$58.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$58.15
Rate for Payer: LLUH Dept of Risk Management WC	$53.31
Rate for Payer: Multiplan Commercial	$72.69

ELETRIPTAN 20 MG TABLET [34683]

Facility

$96.92

Service Code	NDC 0049-2330-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$53.31
Max. Negotiated Rate	$77.54
Rate for Payer: Cash Price	$53.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$77.54
Rate for Payer: Health Smart Auto/Commercial	$58.15
Rate for Payer: LLUH Dept of Risk Management WC	$53.31
Rate for Payer: Multiplan Commercial	$72.69

ELTROMBOPAG OLAMINE 25 MG TABLET [94579]

Facility

$313.06

Service Code	NDC 0078-0685-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$172.18
Max. Negotiated Rate	$250.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$187.84
Rate for Payer: Aetna of CA Government/Medicare	$187.84
Rate for Payer: Cash Price	$172.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$250.45
Rate for Payer: Health Smart Auto/Commercial	$187.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$187.84
Rate for Payer: LLUH Dept of Risk Management WC	$172.18
Rate for Payer: Multiplan Commercial	$234.79

ELTROMBOPAG OLAMINE 25 MG TABLET [94579]

Facility

$313.06

Service Code	NDC 0078-0685-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$172.18
Max. Negotiated Rate	$250.45
Rate for Payer: Cash Price	$172.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$250.45
Rate for Payer: Health Smart Auto/Commercial	$187.84
Rate for Payer: LLUH Dept of Risk Management WC	$172.18
Rate for Payer: Multiplan Commercial	$234.79

ELTROMBOPAG OLAMINE 50 MG TABLET [94580]

Facility

$566.53

Service Code	NDC 0078-0686-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$311.59
Max. Negotiated Rate	$453.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$339.92
Rate for Payer: Aetna of CA Government/Medicare	$339.92
Rate for Payer: Cash Price	$311.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$453.22
Rate for Payer: Health Smart Auto/Commercial	$339.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$339.92
Rate for Payer: LLUH Dept of Risk Management WC	$311.59
Rate for Payer: Multiplan Commercial	$424.90

ELTROMBOPAG OLAMINE 50 MG TABLET [94580]

Facility

$566.53

Service Code	NDC 0078-0686-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$311.59
Max. Negotiated Rate	$453.22
Rate for Payer: Cash Price	$311.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$453.22
Rate for Payer: Health Smart Auto/Commercial	$339.92
Rate for Payer: LLUH Dept of Risk Management WC	$311.59
Rate for Payer: Multiplan Commercial	$424.90

EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]

Facility

$1.33

Service Code	NDC 0187-5110-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$1.00

EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]

Facility

$1.33

Service Code	NDC 0187-5110-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$1.00

EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]

Facility

$0.58

Service Code	NDC 5898096012
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]

Facility

$0.58

Service Code	NDC 5898096012
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

Know your out-of-pocket cost for care.

All Charges