Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 68001-593-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 43547-282-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.52

Service Code	NDC 65162-705-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.76

Service Code	NDC 31722-569-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.61
Rate for Payer: Cash Price	$0.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Commercial	$0.57

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.76

Service Code	NDC 31722-569-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Cash Price	$0.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Commercial	$0.57

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.52

Service Code	NDC 65162-705-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.43

Service Code	NDC 60687-865-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
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	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
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	$0.32

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 68001-591-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.43

Service Code	NDC 60687-865-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
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	$0.32

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 43547-280-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 16729-168-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 43547-280-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 16729-168-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 68001-591-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.43

Service Code	NDC 60687-865-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
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	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
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	$0.32

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.43

Service Code	NDC 60687-865-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
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	$0.32

ESLICARBAZEPINE 200 MG TABLET [204958]

Facility

$53.88

Service Code	NDC 63402-202-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 200 MG TABLET [204958]

Facility

$53.88

Service Code	NDC 63402-202-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.33
Rate for Payer: Aetna of CA Government/Medicare	$32.33
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 400 MG TABLET [204960]

Facility

$53.88

Service Code	NDC 63402-204-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.33
Rate for Payer: Aetna of CA Government/Medicare	$32.33
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 400 MG TABLET [204960]

Facility

$53.88

Service Code	NDC 63402-204-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 600 MG TABLET [204961]

Facility

$53.88

Service Code	NDC 63402-206-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.33
Rate for Payer: Aetna of CA Government/Medicare	$32.33
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 600 MG TABLET [204961]

Facility

$53.88

Service Code	NDC 63402-206-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 800 MG TABLET [204959]

Facility

$53.88

Service Code	NDC 63402-208-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

ESLICARBAZEPINE 800 MG TABLET [204959]

Facility

$29.10

Service Code	NDC 68180-293-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.46
Rate for Payer: Aetna of CA Government/Medicare	$17.46
Rate for Payer: Cash Price	$16.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.28
Rate for Payer: Health Smart Auto/Commercial	$17.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.46
Rate for Payer: LLUH Dept of Risk Management WC	$16.00
Rate for Payer: Multiplan Commercial	$21.82

ESLICARBAZEPINE 800 MG TABLET [204959]

Facility

$53.88

Service Code	NDC 63402-208-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$29.63
Max. Negotiated Rate	$43.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.33
Rate for Payer: Aetna of CA Government/Medicare	$32.33
Rate for Payer: Cash Price	$29.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.10
Rate for Payer: Health Smart Auto/Commercial	$32.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.33
Rate for Payer: LLUH Dept of Risk Management WC	$29.63
Rate for Payer: Multiplan Commercial	$40.41

Know your out-of-pocket cost for care.

All Charges