Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

EMTRICITABINE 200 MG CAPSULE [36252]

Facility

$18.54

Service Code	NDC 69097-642-02
Hospital Charge Code	1711928
Hospital Revenue Code	259
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$14.83
Rate for Payer: Cash Price	$8.34
Rate for Payer: Cigna of CA HMO/PPO	$14.83
Rate for Payer: Health Smart Auto/Commercial	$11.12
Rate for Payer: LLUH Dept of Risk Management WC	$10.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.90

EMTRICITABINE 200 MG CAPSULE [36252]

Facility

$18.54

Service Code	NDC 69097-642-02
Hospital Charge Code	1711928
Hospital Revenue Code	259
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$13.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.12
Rate for Payer: Aetna of CA Government/Medicare	$11.12
Rate for Payer: Cash Price	$8.34
Rate for Payer: Health Smart Auto/Commercial	$11.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.12
Rate for Payer: LLUH Dept of Risk Management WC	$10.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.90

EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET [214124]

Facility

$86.37

Service Code	NDC 61958-2002-1
Hospital Charge Code	ERX214124
Hospital Revenue Code	259
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$64.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.82
Rate for Payer: Aetna of CA Government/Medicare	$51.82
Rate for Payer: Cash Price	$38.87
Rate for Payer: Health Smart Auto/Commercial	$51.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.82
Rate for Payer: LLUH Dept of Risk Management WC	$47.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.78

EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET [214124]

Facility

$86.37

Service Code	NDC 61958-2002-1
Hospital Charge Code	ERX214124
Hospital Revenue Code	259
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$69.10
Rate for Payer: Health Smart Auto/Commercial	$51.82
Rate for Payer: Cash Price	$38.87
Rate for Payer: Cigna of CA HMO/PPO	$69.10
Rate for Payer: LLUH Dept of Risk Management WC	$47.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.78

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]

Facility

$1.00

Service Code	CPT J0750
Hospital Charge Code	1710978
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]

Facility

$1.00

Service Code	CPT J0750
Hospital Charge Code	1710978
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 0143-9787-10
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$2.87
Rate for Payer: Cigna of CA HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 0143-9787-01
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 0143-9787-01
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$2.87
Rate for Payer: Cigna of CA HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 43598-078-58
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 43598-169-11
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cigna of CA HMO/PPO	$4.55
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 43598-169-58
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cigna of CA HMO/PPO	$4.55
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 0143-9787-10
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 0143-9786-01
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cigna of CA HMO/PPO	$4.55
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 0143-9786-10
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cigna of CA HMO/PPO	$4.55
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 0143-9786-10
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.41
Rate for Payer: Aetna of CA Government/Medicare	$3.41
Rate for Payer: Cash Price	$2.56
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 43598-169-11
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.41
Rate for Payer: Aetna of CA Government/Medicare	$3.41
Rate for Payer: Cash Price	$2.56
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 43598-078-11
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$2.87
Rate for Payer: Cigna of CA HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 43598-169-58
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.41
Rate for Payer: Aetna of CA Government/Medicare	$3.41
Rate for Payer: Cash Price	$2.56
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$5.69

Service Code	NDC 0143-9786-01
Hospital Charge Code	1754284
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.41
Rate for Payer: Aetna of CA Government/Medicare	$3.41
Rate for Payer: Cash Price	$2.56
Rate for Payer: Health Smart Auto/Commercial	$3.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.41
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.27

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 43598-078-11
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION [9929]

Facility

$6.37

Service Code	NDC 43598-078-58
Hospital Charge Code	1721216
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$2.87
Rate for Payer: Cigna of CA HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

ENALAPRIL MALEATE 10 MG TABLET [9924]

Facility

$0.27

Service Code	NDC 43547-547-10
Hospital Charge Code	1711458
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

ENALAPRIL MALEATE 10 MG TABLET [9924]

Facility

$0.27

Service Code	NDC 43547-547-10
Hospital Charge Code	1711458
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

ENALAPRIL MALEATE 10 MG TABLET [9924]

Facility

$0.60

Service Code	NDC 64679-925-02
Hospital Charge Code	1711458
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

Know your out-of-pocket cost for care.

All Charges