Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ECONAZOLE 1 % TOPICAL CREAM [9915]

Facility

$4.00

Service Code	NDC 51672-1303-1
Hospital Charge Code	NDG9915
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

ECONAZOLE 1 % TOPICAL CREAM [9915]

Facility

$4.00

Service Code	NDC 51672-1303-1
Hospital Charge Code	NDG9915
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]

Facility

$260.92

Service Code	CPT J1300
Hospital Charge Code	NDG81696
Hospital Revenue Code	636
Min. Negotiated Rate	$143.51
Max. Negotiated Rate	$195.69
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	$117.41
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 Beech St/Commercial/PHCS	$195.69

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]

Facility

$260.92

Service Code	CPT J1300
Hospital Charge Code	NDG81696
Hospital Revenue Code	636
Min. Negotiated Rate	$143.51
Max. Negotiated Rate	$208.74
Rate for Payer: Cash Price	$117.41
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$195.69

EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]

Facility

$1,292.51

Service Code	CPT J0600
Hospital Charge Code	NDG9916
Hospital Revenue Code	636
Min. Negotiated Rate	$710.88
Max. Negotiated Rate	$1,034.01
Rate for Payer: Cash Price	$581.63
Rate for Payer: Cigna of CA HMO/PPO	$1,034.01
Rate for Payer: Health Smart Auto/Commercial	$775.51
Rate for Payer: LLUH Dept of Risk Management WC	$710.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$969.38

EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]

Facility

$1,292.51

Service Code	CPT J0600
Hospital Charge Code	NDG9916
Hospital Revenue Code	636
Min. Negotiated Rate	$710.88
Max. Negotiated Rate	$969.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$775.51
Rate for Payer: Aetna of CA Government/Medicare	$775.51
Rate for Payer: Cash Price	$581.63
Rate for Payer: Health Smart Auto/Commercial	$775.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$775.51
Rate for Payer: LLUH Dept of Risk Management WC	$710.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$969.38

EDETATE DISODIUM 3 % EYE DROPS [222529]

Facility

$30.00

Service Code	CPT J3490
Hospital Charge Code	NDG222529
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$22.50

EDETATE DISODIUM 3 % EYE DROPS [222529]

Facility

$30.00

Service Code	CPT J3490
Hospital Charge Code	NDG222529
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
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	$13.50
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 Beech St/Commercial/PHCS	$22.50

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	1711878
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.40

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	1711878
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.40
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	$1.44
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 Beech St/Commercial/PHCS	$2.40

EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]

Facility

$9,000.00

Service Code	CPT J1449
Hospital Charge Code	NDG235968
Hospital Revenue Code	636
Min. Negotiated Rate	$4,950.00
Max. Negotiated Rate	$7,200.00
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Cigna of CA HMO/PPO	$7,200.00
Rate for Payer: Health Smart Auto/Commercial	$5,400.00
Rate for Payer: LLUH Dept of Risk Management WC	$4,950.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,750.00

EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]

Facility

$9,000.00

Service Code	CPT J1449
Hospital Charge Code	NDG235968
Hospital Revenue Code	636
Min. Negotiated Rate	$4,950.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,400.00
Rate for Payer: Aetna of CA Government/Medicare	$5,400.00
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Health Smart Auto/Commercial	$5,400.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,400.00
Rate for Payer: LLUH Dept of Risk Management WC	$4,950.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,750.00

ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]

Facility

$0.01

Service Code	NDC 0338-0179-04
Hospital Charge Code	1759936
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.01

ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]

Facility

$0.01

Service Code	NDC 0338-0179-04
Hospital Charge Code	1759936
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: 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 Beech St/Commercial/PHCS	$0.01

ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]

Facility

$0.02

Service Code	NDC 0338-0221-04
Hospital Charge Code	1771306
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.02

ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]

Facility

$0.02

Service Code	NDC 0338-0221-04
Hospital Charge Code	1771306
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: 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 Beech St/Commercial/PHCS	$0.02

ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
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: 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 Beech St/Commercial/PHCS	$0.01

ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.01

ELECTROLYTE-S IV BOLUS [192101]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.01

ELECTROLYTE-S IV BOLUS [192101]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
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: 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 Beech St/Commercial/PHCS	$0.01

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

Facility

$0.01

Service Code	NDC 0264-7707-00
Hospital Charge Code	1759610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.01

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

Facility

$0.01

Service Code	NDC 0264-7707-00
Hospital Charge Code	1759610
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: 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 Beech St/Commercial/PHCS	$0.01

ELETRIPTAN 20 MG TABLET [34683]

Facility

$92.31

Service Code	NDC 0049-2330-45
Hospital Charge Code	1710964
Hospital Revenue Code	259
Min. Negotiated Rate	$50.77
Max. Negotiated Rate	$73.85
Rate for Payer: Cash Price	$41.54
Rate for Payer: Cigna of CA HMO/PPO	$73.85
Rate for Payer: Health Smart Auto/Commercial	$55.39
Rate for Payer: LLUH Dept of Risk Management WC	$50.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.23

ELETRIPTAN 20 MG TABLET [34683]

Facility

$92.31

Service Code	NDC 0049-2330-45
Hospital Charge Code	1710964
Hospital Revenue Code	259
Min. Negotiated Rate	$50.77
Max. Negotiated Rate	$69.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.39
Rate for Payer: Aetna of CA Government/Medicare	$55.39
Rate for Payer: Cash Price	$41.54
Rate for Payer: Health Smart Auto/Commercial	$55.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.39
Rate for Payer: LLUH Dept of Risk Management WC	$50.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.23

ELETRIPTAN 40 MG TABLET [34684]

Facility

$92.31

Service Code	NDC 0049-2340-45
Hospital Charge Code	1711914
Hospital Revenue Code	259
Min. Negotiated Rate	$50.77
Max. Negotiated Rate	$69.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.39
Rate for Payer: Aetna of CA Government/Medicare	$55.39
Rate for Payer: Cash Price	$41.54
Rate for Payer: Health Smart Auto/Commercial	$55.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.39
Rate for Payer: LLUH Dept of Risk Management WC	$50.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.23

Know your out-of-pocket cost for care.

All Charges