Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 16729-170-01
Hospital Charge Code	1711818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.14

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 16729-170-01
Hospital Charge Code	1711818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 68001-456-00
Hospital Charge Code	1711818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.14

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 43547-282-10
Hospital Charge Code	1711818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

ESCITALOPRAM 20 MG TABLET [33513]

Facility

$0.18

Service Code	NDC 68001-456-00
Hospital Charge Code	1711818
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.80

Service Code	NDC 54838-551-70
Hospital Charge Code	1715224
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.80

Service Code	NDC 54838-551-70
Hospital Charge Code	1715224
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.76

Service Code	NDC 31722-569-24
Hospital Charge Code	1715224
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.57
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	$0.34
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 Beech St/Commercial/PHCS	$0.57

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.53

Service Code	NDC 65162-705-88
Hospital Charge Code	1715224
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.53

Service Code	NDC 65162-705-88
Hospital Charge Code	1715224
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION [34897]

Facility

$0.76

Service Code	NDC 31722-569-24
Hospital Charge Code	1715224
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.61
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.57

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 68001-454-00
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
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	$0.05
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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 43547-280-10
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 68001-591-00
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
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	$0.05
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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 43547-280-10
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
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	$0.05
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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 68001-591-00
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.21

Service Code	NDC 68180-137-01
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
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	$0.09
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 Beech St/Commercial/PHCS	$0.16

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 16729-168-01
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
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	$0.05
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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.21

Service Code	NDC 68180-137-01
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 68001-454-00
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.09

ESCITALOPRAM 5 MG TABLET [37635]

Facility

$0.12

Service Code	NDC 16729-168-01
Hospital Charge Code	1712491
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.09

ESLICARBAZEPINE 200 MG TABLET [204958]

Facility

$47.95

Service Code	NDC 63402-202-30
Hospital Charge Code	ERX204958
Hospital Revenue Code	259
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$38.36
Rate for Payer: Cash Price	$21.58
Rate for Payer: Cigna of CA HMO/PPO	$38.36
Rate for Payer: Health Smart Auto/Commercial	$28.77
Rate for Payer: LLUH Dept of Risk Management WC	$26.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.96

ESLICARBAZEPINE 200 MG TABLET [204958]

Facility

$47.95

Service Code	NDC 63402-202-30
Hospital Charge Code	ERX204958
Hospital Revenue Code	259
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$35.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.77
Rate for Payer: Aetna of CA Government/Medicare	$28.77
Rate for Payer: Cash Price	$21.58
Rate for Payer: Health Smart Auto/Commercial	$28.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.77
Rate for Payer: LLUH Dept of Risk Management WC	$26.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.96

ESLICARBAZEPINE 400 MG TABLET [204960]

Facility

$47.95

Service Code	NDC 63402-204-30
Hospital Charge Code	ERX204960
Hospital Revenue Code	259
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$35.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.77
Rate for Payer: Aetna of CA Government/Medicare	$28.77
Rate for Payer: Cash Price	$21.58
Rate for Payer: Health Smart Auto/Commercial	$28.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.77
Rate for Payer: LLUH Dept of Risk Management WC	$26.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.96

ESLICARBAZEPINE 400 MG TABLET [204960]

Facility

$47.95

Service Code	NDC 63402-204-30
Hospital Charge Code	ERX204960
Hospital Revenue Code	259
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$38.36
Rate for Payer: Cash Price	$21.58
Rate for Payer: Cigna of CA HMO/PPO	$38.36
Rate for Payer: Health Smart Auto/Commercial	$28.77
Rate for Payer: LLUH Dept of Risk Management WC	$26.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.96

Know your out-of-pocket cost for care.

All Charges