Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$2.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.79
Rate for Payer: Aetna of CA Government/Medicare	$1.79
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 16729-114-31
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

$2.25

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 50 MG CAPSULE [10001]

Facility

$90.40

Service Code	CPT J8560
Hospital Charge Code	1711528
Hospital Revenue Code	636
Min. Negotiated Rate	$49.72
Max. Negotiated Rate	$72.32
Rate for Payer: Cash Price	$40.68
Rate for Payer: Cigna of CA HMO/PPO	$72.32
Rate for Payer: Health Smart Auto/Commercial	$54.24
Rate for Payer: LLUH Dept of Risk Management WC	$49.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.80

ETOPOSIDE 50 MG CAPSULE [10001]

Facility

$90.40

Service Code	CPT J8560
Hospital Charge Code	1711528
Hospital Revenue Code	636
Min. Negotiated Rate	$49.72
Max. Negotiated Rate	$67.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.24
Rate for Payer: Aetna of CA Government/Medicare	$54.24
Rate for Payer: Cash Price	$40.68
Rate for Payer: Health Smart Auto/Commercial	$54.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.24
Rate for Payer: LLUH Dept of Risk Management WC	$49.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.80

ETOPOSIDE ORAL SOLUTION COMPOUND 10 MG/ML [4080272]

Facility

$1.00

Service Code	NDC 9994-0802-72
Hospital Charge Code	ERX4080272
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

ETOPOSIDE ORAL SOLUTION COMPOUND 10 MG/ML [4080272]

Facility

$1.00

Service Code	NDC 9994-0802-72
Hospital Charge Code	ERX4080272
Hospital Revenue Code	259
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 Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

ETRAVIRINE 100 MG TABLET [89432]

Facility

$14.69

Service Code	NDC 59676-570-01
Hospital Charge Code	1712396
Hospital Revenue Code	259
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.81
Rate for Payer: Aetna of CA Government/Medicare	$8.81
Rate for Payer: Cash Price	$6.61
Rate for Payer: Health Smart Auto/Commercial	$8.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.81
Rate for Payer: LLUH Dept of Risk Management WC	$8.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.02

ETRAVIRINE 100 MG TABLET [89432]

Facility

$14.69

Service Code	NDC 59676-570-01
Hospital Charge Code	1712396
Hospital Revenue Code	259
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.75
Rate for Payer: Cash Price	$6.61
Rate for Payer: Cigna of CA HMO/PPO	$11.75
Rate for Payer: Health Smart Auto/Commercial	$8.81
Rate for Payer: LLUH Dept of Risk Management WC	$8.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.02

ETRAVIRINE 200 MG TABLET [108431]

Facility

$29.37

Service Code	NDC 59676-571-01
Hospital Charge Code	ERX108431
Hospital Revenue Code	259
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$23.50
Rate for Payer: Cash Price	$13.22
Rate for Payer: Cigna of CA HMO/PPO	$23.50
Rate for Payer: Health Smart Auto/Commercial	$17.62
Rate for Payer: LLUH Dept of Risk Management WC	$16.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.03

ETRAVIRINE 200 MG TABLET [108431]

Facility

$29.37

Service Code	NDC 59676-571-01
Hospital Charge Code	ERX108431
Hospital Revenue Code	259
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$22.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.62
Rate for Payer: Aetna of CA Government/Medicare	$17.62
Rate for Payer: Cash Price	$13.22
Rate for Payer: Health Smart Auto/Commercial	$17.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.62
Rate for Payer: LLUH Dept of Risk Management WC	$16.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.03

EVEROLIMUS 0.3 MG/ML SPECIAL DILUTION (FROM 0.75 MG TAB) [4081261]

Facility

$36.50

Service Code	CPT J7527
Hospital Charge Code	ERX4081261
Hospital Revenue Code	636
Min. Negotiated Rate	$20.08
Max. Negotiated Rate	$27.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.90
Rate for Payer: Aetna of CA Government/Medicare	$21.90
Rate for Payer: Cash Price	$16.43
Rate for Payer: Health Smart Auto/Commercial	$21.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.90
Rate for Payer: LLUH Dept of Risk Management WC	$20.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.38

EVEROLIMUS 0.3 MG/ML SPECIAL DILUTION (FROM 0.75 MG TAB) [4081261]

Facility

$36.50

Service Code	CPT J7527
Hospital Charge Code	ERX4081261
Hospital Revenue Code	636
Min. Negotiated Rate	$20.08
Max. Negotiated Rate	$29.20
Rate for Payer: Cash Price	$16.43
Rate for Payer: Cigna of CA HMO/PPO	$29.20
Rate for Payer: Health Smart Auto/Commercial	$21.90
Rate for Payer: LLUH Dept of Risk Management WC	$20.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.38

EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET [104555]

Facility

$12.16

Service Code	CPT J7527
Hospital Charge Code	1712485
Hospital Revenue Code	259
Min. Negotiated Rate	$6.69
Max. Negotiated Rate	$9.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.30
Rate for Payer: Aetna of CA Government/Medicare	$7.30
Rate for Payer: Cash Price	$5.47
Rate for Payer: Health Smart Auto/Commercial	$7.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.12

EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET [104555]

Facility

$12.16

Service Code	CPT J7527
Hospital Charge Code	1712485
Hospital Revenue Code	259
Min. Negotiated Rate	$6.69
Max. Negotiated Rate	$9.73
Rate for Payer: Cash Price	$5.47
Rate for Payer: Cigna of CA HMO/PPO	$9.73
Rate for Payer: Health Smart Auto/Commercial	$7.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.12

EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG TABLET [104877]

Facility

$19.03

Service Code	CPT J7527
Hospital Charge Code	1712486
Hospital Revenue Code	636
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$14.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.62
Rate for Payer: Aetna of CA Government/Medicare	$14.62
Rate for Payer: Aetna of CA Government/Medicare	$11.42
Rate for Payer: Aetna of CA Government/Medicare	$14.59
Rate for Payer: Cash Price	$10.96
Rate for Payer: Cash Price	$8.56
Rate for Payer: Cash Price	$10.94
Rate for Payer: Health Smart Auto/Commercial	$14.62
Rate for Payer: Health Smart Auto/Commercial	$11.42
Rate for Payer: Health Smart Auto/Commercial	$14.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.62
Rate for Payer: LLUH Dept of Risk Management WC	$13.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.37
Rate for Payer: LLUH Dept of Risk Management WC	$10.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.27

EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG TABLET [104877]

Facility

$19.03

Service Code	CPT J7527
Hospital Charge Code	1712486
Hospital Revenue Code	636
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$15.22
Rate for Payer: Cash Price	$8.56
Rate for Payer: Cash Price	$10.96
Rate for Payer: Cash Price	$10.94
Rate for Payer: Cigna of CA HMO/PPO	$19.45
Rate for Payer: Cigna of CA HMO/PPO	$19.49
Rate for Payer: Cigna of CA HMO/PPO	$15.22
Rate for Payer: Health Smart Auto/Commercial	$11.42
Rate for Payer: Health Smart Auto/Commercial	$14.59
Rate for Payer: Health Smart Auto/Commercial	$14.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$13.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.23

EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.75 MG TABLET [104556]

Facility

$36.50

Service Code	CPT J7527
Hospital Charge Code	1712487
Hospital Revenue Code	636
Min. Negotiated Rate	$20.08
Max. Negotiated Rate	$27.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.90
Rate for Payer: Aetna of CA Government/Medicare	$21.90
Rate for Payer: Cash Price	$16.43
Rate for Payer: Health Smart Auto/Commercial	$21.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.90
Rate for Payer: LLUH Dept of Risk Management WC	$20.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.38

EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.75 MG TABLET [104556]

Facility

$36.50

Service Code	CPT J7527
Hospital Charge Code	1712487
Hospital Revenue Code	636
Min. Negotiated Rate	$20.08
Max. Negotiated Rate	$29.20
Rate for Payer: Cash Price	$16.43
Rate for Payer: Cigna of CA HMO/PPO	$29.20
Rate for Payer: Health Smart Auto/Commercial	$21.90
Rate for Payer: LLUH Dept of Risk Management WC	$20.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.38

EXEMESTANE 25 MG TABLET [26551]

Facility

$46.05

Service Code	NDC 0009-7663-04
Hospital Charge Code	1711985
Hospital Revenue Code	259
Min. Negotiated Rate	$25.33
Max. Negotiated Rate	$36.84
Rate for Payer: Cash Price	$20.72
Rate for Payer: Cigna of CA HMO/PPO	$36.84
Rate for Payer: Health Smart Auto/Commercial	$27.63
Rate for Payer: LLUH Dept of Risk Management WC	$25.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.54

EXEMESTANE 25 MG TABLET [26551]

Facility

$13.03

Service Code	NDC 0054-0080-13
Hospital Charge Code	1711985
Hospital Revenue Code	259
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$10.42
Rate for Payer: Cash Price	$5.86
Rate for Payer: Cigna of CA HMO/PPO	$10.42
Rate for Payer: Health Smart Auto/Commercial	$7.82
Rate for Payer: LLUH Dept of Risk Management WC	$7.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.77

EXEMESTANE 25 MG TABLET [26551]

Facility

$46.05

Service Code	NDC 0009-7663-04
Hospital Charge Code	1711985
Hospital Revenue Code	259
Min. Negotiated Rate	$25.33
Max. Negotiated Rate	$34.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.63
Rate for Payer: Aetna of CA Government/Medicare	$27.63
Rate for Payer: Cash Price	$20.72
Rate for Payer: Health Smart Auto/Commercial	$27.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.63
Rate for Payer: LLUH Dept of Risk Management WC	$25.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.54

EXEMESTANE 25 MG TABLET [26551]

Facility

$13.03

Service Code	NDC 0054-0080-13
Hospital Charge Code	1711985
Hospital Revenue Code	259
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$9.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.82
Rate for Payer: Aetna of CA Government/Medicare	$7.82
Rate for Payer: Cash Price	$5.86
Rate for Payer: Health Smart Auto/Commercial	$7.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.82
Rate for Payer: LLUH Dept of Risk Management WC	$7.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.77

EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]

Facility

$13.67

Service Code	NDC 66582-312-31
Hospital Charge Code	1710951
Hospital Revenue Code	259
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$10.94
Rate for Payer: Cash Price	$6.15
Rate for Payer: Cigna of CA HMO/PPO	$10.94
Rate for Payer: Health Smart Auto/Commercial	$8.20
Rate for Payer: LLUH Dept of Risk Management WC	$7.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.25

EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]

Facility

$13.67

Service Code	NDC 66582-312-31
Hospital Charge Code	1710951
Hospital Revenue Code	259
Min. Negotiated Rate	$7.52
Max. Negotiated Rate	$10.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.20
Rate for Payer: Aetna of CA Government/Medicare	$8.20
Rate for Payer: Cash Price	$6.15
Rate for Payer: Health Smart Auto/Commercial	$8.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.20
Rate for Payer: LLUH Dept of Risk Management WC	$7.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.25

Know your out-of-pocket cost for care.

All Charges