Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$1.30

Service Code	NDC 68084-280-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$1.52

Service Code	NDC 68180-281-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Commercial	$1.14

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$1.30

Service Code	NDC 68084-280-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$1.30

Service Code	NDC 68084-280-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$1.30

Service Code	NDC 68084-280-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

ETHAMBUTOL 400 MG TABLET [9983]

Facility

$1.52

Service Code	NDC 68180-281-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Commercial	$1.14

ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]

Facility

$0.22

Service Code	NDC 9994-0802-71
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]

Facility

$0.22

Service Code	NDC 9994-0802-71
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

ETHANOL (ALCOHOL) 40 % [4081380]

Facility

$1.43

Service Code	NDC 9994-0813-80
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.07

ETHANOL (ALCOHOL) 40 % [4081380]

Facility

$1.43

Service Code	NDC 9994-0813-80
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.07

ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]

Facility

$302.34

Service Code	HCPCS J1430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.29
Max. Negotiated Rate	$241.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$181.40
Rate for Payer: Aetna of CA Government/Medicare	$181.40
Rate for Payer: Cash Price	$166.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$241.87
Rate for Payer: Health Smart Auto/Commercial	$181.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$181.40
Rate for Payer: LLUH Dept of Risk Management WC	$166.29
Rate for Payer: Multiplan Commercial	$226.75

ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]

Facility

$302.34

Service Code	HCPCS J1430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.29
Max. Negotiated Rate	$241.87
Rate for Payer: Cash Price	$166.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$241.87
Rate for Payer: Health Smart Auto/Commercial	$181.40
Rate for Payer: LLUH Dept of Risk Management WC	$166.29
Rate for Payer: Multiplan Commercial	$226.75

ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]

Facility

$146.88

Service Code	NDC 67684-1901-2
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$80.78
Max. Negotiated Rate	$117.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$88.13
Rate for Payer: Aetna of CA Government/Medicare	$88.13
Rate for Payer: Cash Price	$80.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.50
Rate for Payer: Health Smart Auto/Commercial	$88.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$88.13
Rate for Payer: LLUH Dept of Risk Management WC	$80.78
Rate for Payer: Multiplan Commercial	$110.16

ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]

Facility

$146.88

Service Code	NDC 67684-1901-2
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$80.78
Max. Negotiated Rate	$117.50
Rate for Payer: Cash Price	$80.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.50
Rate for Payer: Health Smart Auto/Commercial	$88.13
Rate for Payer: LLUH Dept of Risk Management WC	$80.78
Rate for Payer: Multiplan Commercial	$110.16

ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]

Facility

$0.14

Service Code	NDC 0121-0670-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]

Facility

$0.14

Service Code	NDC 0121-0670-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

ETHOSUXIMIDE 250 MG CAPSULE [9989]

Facility

$0.50

Service Code	NDC 64380-878-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

ETHOSUXIMIDE 250 MG CAPSULE [9989]

Facility

$0.50

Service Code	NDC 64380-878-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-15
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$191.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$143.28
Rate for Payer: Aetna of CA Government/Medicare	$143.28
Rate for Payer: Cash Price	$131.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$191.04
Rate for Payer: Health Smart Auto/Commercial	$143.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$143.28
Rate for Payer: LLUH Dept of Risk Management WC	$131.34
Rate for Payer: Multiplan Commercial	$179.10

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$191.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$143.28
Rate for Payer: Aetna of CA Government/Medicare	$143.28
Rate for Payer: Cash Price	$131.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$191.04
Rate for Payer: Health Smart Auto/Commercial	$143.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$143.28
Rate for Payer: LLUH Dept of Risk Management WC	$131.34
Rate for Payer: Multiplan Commercial	$179.10

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-15
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$191.04
Rate for Payer: Cash Price	$131.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$191.04
Rate for Payer: Health Smart Auto/Commercial	$143.28
Rate for Payer: LLUH Dept of Risk Management WC	$131.34
Rate for Payer: Multiplan Commercial	$179.10

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$191.04
Rate for Payer: Cash Price	$131.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$191.04
Rate for Payer: Health Smart Auto/Commercial	$143.28
Rate for Payer: LLUH Dept of Risk Management WC	$131.34
Rate for Payer: Multiplan Commercial	$179.10

ETHYL ALCOHOL (BULK) LIQUID [16626]

Facility

$0.37

Service Code	NDC 3877906161
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

ETHYL ALCOHOL (BULK) LIQUID [16626]

Facility

$0.37

Service Code	NDC 3877906161
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]

Facility

$0.36

Service Code	NDC 9999-9929-51
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

Know your out-of-pocket cost for care.

All Charges