Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ESTRADIOL 0.5 MG TABLET [12491]

Facility

$0.32

Service Code	NDC 51862-332-01
Hospital Charge Code	1712562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

ESTRADIOL 0.5 MG TABLET [12491]

Facility

$0.09

Service Code	NDC 42806-087-01
Hospital Charge Code	1712562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

ESTRADIOL 0.5 MG TABLET [12491]

Facility

$0.32

Service Code	NDC 51862-332-01
Hospital Charge Code	1712562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

ESTRADIOL 0.5 MG TABLET [12491]

Facility

$0.09

Service Code	NDC 42806-087-01
Hospital Charge Code	1712562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

ESTRADIOL 1 MG TABLET [9967]

Facility

$0.10

Service Code	NDC 42806-088-01
Hospital Charge Code	1710537
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

ESTRADIOL 1 MG TABLET [9967]

Facility

$0.10

Service Code	NDC 42806-088-01
Hospital Charge Code	1710537
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

ESTRADIOL 2 MG TABLET [9968]

Facility

$0.17

Service Code	NDC 42806-089-01
Hospital Charge Code	1710546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
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	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

ESTRADIOL 2 MG TABLET [9968]

Facility

$0.48

Service Code	NDC 0555-0887-02
Hospital Charge Code	1710546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

ESTRADIOL 2 MG TABLET [9968]

Facility

$0.48

Service Code	NDC 51862-334-01
Hospital Charge Code	1710546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

ESTRADIOL 2 MG TABLET [9968]

Facility

$0.17

Service Code	NDC 42806-089-01
Hospital Charge Code	1710546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

ESTRADIOL 2 MG TABLET [9968]

Facility

$0.48

Service Code	NDC 0555-0887-02
Hospital Charge Code	1710546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

ESTRADIOL 2 MG TABLET [9968]

Facility

$0.48

Service Code	NDC 51862-334-01
Hospital Charge Code	1710546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]

Facility

$74.47

Service Code	CPT J1380
Hospital Charge Code	1720187
Hospital Revenue Code	636
Min. Negotiated Rate	$40.96
Max. Negotiated Rate	$55.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.68
Rate for Payer: Aetna of CA Government/Medicare	$44.68
Rate for Payer: Cash Price	$33.51
Rate for Payer: Health Smart Auto/Commercial	$44.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.68
Rate for Payer: LLUH Dept of Risk Management WC	$40.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.85

ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]

Facility

$74.47

Service Code	CPT J1380
Hospital Charge Code	1720187
Hospital Revenue Code	636
Min. Negotiated Rate	$40.96
Max. Negotiated Rate	$59.58
Rate for Payer: Cash Price	$33.51
Rate for Payer: Cigna of CA HMO/PPO	$59.58
Rate for Payer: Health Smart Auto/Commercial	$44.68
Rate for Payer: LLUH Dept of Risk Management WC	$40.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.85

ESZOPICLONE 1 MG TABLET [40320]

Facility

$0.30

Service Code	NDC 55111-629-30
Hospital Charge Code	1712286
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

ESZOPICLONE 1 MG TABLET [40320]

Facility

$0.30

Service Code	NDC 55111-629-30
Hospital Charge Code	1712286
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]

Facility

$224.71

Service Code	CPT J0606
Hospital Charge Code	NDG219855
Hospital Revenue Code	636
Min. Negotiated Rate	$123.59
Max. Negotiated Rate	$168.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$134.83
Rate for Payer: Aetna of CA Government/Medicare	$134.83
Rate for Payer: Cash Price	$101.12
Rate for Payer: Health Smart Auto/Commercial	$134.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$134.83
Rate for Payer: LLUH Dept of Risk Management WC	$123.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$168.53

ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]

Facility

$224.71

Service Code	CPT J0606
Hospital Charge Code	NDG219855
Hospital Revenue Code	636
Min. Negotiated Rate	$123.59
Max. Negotiated Rate	$179.77
Rate for Payer: Cash Price	$101.12
Rate for Payer: Cigna of CA HMO/PPO	$179.77
Rate for Payer: Health Smart Auto/Commercial	$134.83
Rate for Payer: LLUH Dept of Risk Management WC	$123.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$168.53

ETHACRYNIC ACID 25 MG TABLET [9980]

Facility

$29.33

Service Code	NDC 25010-215-15
Hospital Charge Code	1710113
Hospital Revenue Code	259
Min. Negotiated Rate	$16.13
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.60
Rate for Payer: Aetna of CA Government/Medicare	$17.60
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Smart Auto/Commercial	$17.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.60
Rate for Payer: LLUH Dept of Risk Management WC	$16.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.00

ETHACRYNIC ACID 25 MG TABLET [9980]

Facility

$3.00

Service Code	NDC 0832-1690-11
Hospital Charge Code	1710113
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

ETHACRYNIC ACID 25 MG TABLET [9980]

Facility

$3.00

Service Code	NDC 0832-1690-11
Hospital Charge Code	1710113
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

ETHACRYNIC ACID 25 MG TABLET [9980]

Facility

$29.33

Service Code	NDC 25010-215-15
Hospital Charge Code	1710113
Hospital Revenue Code	259
Min. Negotiated Rate	$16.13
Max. Negotiated Rate	$23.46
Rate for Payer: Cash Price	$13.20
Rate for Payer: Cigna of CA HMO/PPO	$23.46
Rate for Payer: Health Smart Auto/Commercial	$17.60
Rate for Payer: LLUH Dept of Risk Management WC	$16.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.00

ETHACRYNIC ACID 25 MG TABLET [9980]

Facility

$3.00

Service Code	NDC 42799-405-01
Hospital Charge Code	1710113
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

ETHACRYNIC ACID 25 MG TABLET [9980]

Facility

$3.00

Service Code	NDC 42799-405-01
Hospital Charge Code	1710113
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

ETHAMBUTOL 100 MG TABLET [9982]

Facility

$0.58

Service Code	NDC 54879-001-00
Hospital Charge Code	1711051
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

Know your out-of-pocket cost for care.

All Charges