Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-15
Hospital Charge Code	NDG223863
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$179.10
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	$107.46
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 Beech St/Commercial/PHCS	$179.10

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-02
Hospital Charge Code	NDG223863
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$191.04
Rate for Payer: Cash Price	$107.46
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$179.10

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-15
Hospital Charge Code	NDG223863
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$191.04
Rate for Payer: Cash Price	$107.46
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$179.10

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]

Facility

$238.80

Service Code	NDC 54288-105-02
Hospital Charge Code	NDG223863
Hospital Revenue Code	250
Min. Negotiated Rate	$131.34
Max. Negotiated Rate	$179.10
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	$107.46
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 Beech St/Commercial/PHCS	$179.10

ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]

Facility

$0.33

Service Code	NDC 9999-9929-51
Hospital Charge Code	NDC2951
Hospital Revenue Code	272
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]

Facility

$0.33

Service Code	NDC 9999-9929-51
Hospital Charge Code	NDC2951
Hospital Revenue Code	272
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

$0.90

Service Code	NDC 0517-0780-10
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

$0.90

Service Code	NDC 0517-0780-10
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

$0.68

Service Code	NDC 0409-6695-01
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

$0.68

Service Code	NDC 0409-6695-01
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$1.18

Service Code	NDC 67457-902-00
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$0.66

Service Code	NDC 55150-221-10
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$0.66

Service Code	NDC 55150-221-10
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$1.18

Service Code	NDC 67457-902-00
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$1.18

Service Code	NDC 67457-902-10
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

$1.18

Service Code	NDC 67457-902-10
Hospital Charge Code	1720734
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

ETONOGESTREL 68 MG SUBDERMAL IMPLANT [77012]

Facility

$1,310.98

Service Code	CPT J7307
Hospital Charge Code	ERX77012
Hospital Revenue Code	636
Min. Negotiated Rate	$721.04
Max. Negotiated Rate	$983.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$786.59
Rate for Payer: Aetna of CA Government/Medicare	$786.59
Rate for Payer: Cash Price	$589.94
Rate for Payer: Health Smart Auto/Commercial	$786.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$786.59
Rate for Payer: LLUH Dept of Risk Management WC	$721.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$983.24

ETONOGESTREL 68 MG SUBDERMAL IMPLANT [77012]

Facility

$1,310.98

Service Code	CPT J7307
Hospital Charge Code	ERX77012
Hospital Revenue Code	636
Min. Negotiated Rate	$721.04
Max. Negotiated Rate	$1,048.78
Rate for Payer: Cash Price	$589.94
Rate for Payer: Cigna of CA HMO/PPO	$1,048.78
Rate for Payer: Health Smart Auto/Commercial	$786.59
Rate for Payer: LLUH Dept of Risk Management WC	$721.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$983.24

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.25

Service Code	NDC 68001-265-25
Hospital Charge Code	NDG10000A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.80
Rate for Payer: Health Smart Auto/Commercial	$1.35
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna of CA HMO/PPO	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.69

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.99

Service Code	NDC 63323-104-01
Hospital Charge Code	NDG10000A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$2.39
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.39
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: LLUH Dept of Risk Management WC	$1.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.24

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.47

Service Code	NDC 16729-114-08
Hospital Charge Code	NDG10000B
Hospital Revenue Code	636
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.85

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.47

Service Code	NDC 16729-114-31
Hospital Charge Code	NDG10000A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$1.98
Rate for Payer: Cash Price	$1.11
Rate for Payer: Cigna of CA HMO/PPO	$1.98
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.85

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.47

Service Code	NDC 16729-114-31
Hospital Charge Code	NDG10000A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.85

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.25

Service Code	NDC 68001-265-25
Hospital Charge Code	NDG10000A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.35
Rate for Payer: Aetna of CA Government/Medicare	$1.35
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Smart Auto/Commercial	$1.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.35
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.69

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

$2.99

Service Code	NDC 63323-104-05
Hospital Charge Code	NDG10000A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$2.39
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.39
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: LLUH Dept of Risk Management WC	$1.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.24

Know your out-of-pocket cost for care.

All Charges