Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.35

Service Code	NDC 50268-304-11
Hospital Charge Code	1712055
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.48

Service Code	NDC 62332-002-31
Hospital Charge Code	1712055
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

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.35

Service Code	NDC 50268-304-15
Hospital Charge Code	1712055
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.35

Service Code	NDC 50268-304-11
Hospital Charge Code	1712055
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

FAMOTIDINE IN STERILE WATER 2 MG/ML SPECIAL CONCENTRATION [204598]

Facility

$0.14

Service Code	CPT S0028
Hospital Charge Code	1754204
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

FAMOTIDINE IN STERILE WATER 2 MG/ML SPECIAL CONCENTRATION [204598]

Facility

$0.14

Service Code	CPT S0028
Hospital Charge Code	1754204
Hospital Revenue Code	636
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	$0.06
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 Beech St/Commercial/PHCS	$0.11

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [119375]

Facility

$0.53

Service Code	CPT S0028
Hospital Charge Code	1768064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [119375]

Facility

$0.54

Service Code	CPT S0028
Hospital Charge Code	1768064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
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: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [226729]

Facility

$3,178.67

Service Code	NDC 65597-406-01
Hospital Charge Code	ERX226729
Hospital Revenue Code	636
Min. Negotiated Rate	$1,748.27
Max. Negotiated Rate	$2,542.94
Rate for Payer: Cash Price	$1,430.40
Rate for Payer: Cigna of CA HMO/PPO	$2,542.94
Rate for Payer: Health Smart Auto/Commercial	$1,907.20
Rate for Payer: LLUH Dept of Risk Management WC	$1,748.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,384.00

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION [226729]

Facility

$3,178.67

Service Code	NDC 65597-406-01
Hospital Charge Code	ERX226729
Hospital Revenue Code	636
Min. Negotiated Rate	$1,748.27
Max. Negotiated Rate	$2,384.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,907.20
Rate for Payer: Aetna of CA Government/Medicare	$1,907.20
Rate for Payer: Cash Price	$1,430.40
Rate for Payer: Health Smart Auto/Commercial	$1,907.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,907.20
Rate for Payer: LLUH Dept of Risk Management WC	$1,748.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,384.00

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

$0.05

Service Code	NDC 0264-4460-00
Hospital Charge Code	1767008
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

$0.09

Service Code	NDC 0338-0519-14
Hospital Charge Code	1767008
Hospital Revenue Code	250
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

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

$0.05

Service Code	NDC 0264-4460-00
Hospital Charge Code	1767008
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

FAT EMULSION 20 % INTRAVENOUS [10014]

Facility

$0.09

Service Code	NDC 0338-0519-14
Hospital Charge Code	1767008
Hospital Revenue Code	250
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

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-15
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-10
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-40
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-48
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-25
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-55
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-45
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-08
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-20
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-30
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

FAT EMULSION 20 % IV RATE BASED [40840048]

Facility

$0.24

Service Code	NDC L4084-048-25
Hospital Charge Code	ERX40840048
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

Know your out-of-pocket cost for care.

All Charges