Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

APIXABAN 5 MG TABLET [199782]

Facility

$12.13

Service Code	NDC 0003-0894-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.28
Rate for Payer: Aetna of CA Government/Medicare	$7.28
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APIXABAN 5 MG TABLET [199782]

Facility

$12.13

Service Code	NDC 0003-0894-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.28
Rate for Payer: Aetna of CA Government/Medicare	$7.28
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APIXABAN 5 MG TABLET [199782]

Facility

$12.13

Service Code	NDC 0003-0894-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APIXABAN 5 MG TABLET [199782]

Facility

$12.13

Service Code	NDC 0003-0894-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APIXABAN 5 MG TABLET [199782]

Facility

$12.13

Service Code	NDC 0003-0894-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.28
Rate for Payer: Aetna of CA Government/Medicare	$7.28
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APIXABAN 5 MG TABLET [199782]

Facility

$12.13

Service Code	NDC 0003-0894-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APRACLONIDINE 0.5 % EYE DROPS [9119]

Facility

$15.42

Service Code	NDC 61314-665-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.48
Max. Negotiated Rate	$12.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.25
Rate for Payer: Aetna of CA Government/Medicare	$9.25
Rate for Payer: Cash Price	$8.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.34
Rate for Payer: Health Smart Auto/Commercial	$9.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.25
Rate for Payer: LLUH Dept of Risk Management WC	$8.48
Rate for Payer: Multiplan Commercial	$11.56

APRACLONIDINE 0.5 % EYE DROPS [9119]

Facility

$15.42

Service Code	NDC 61314-665-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.48
Max. Negotiated Rate	$12.34
Rate for Payer: Cash Price	$8.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.34
Rate for Payer: Health Smart Auto/Commercial	$9.25
Rate for Payer: LLUH Dept of Risk Management WC	$8.48
Rate for Payer: Multiplan Commercial	$11.56

APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION [220348]

Facility

$30.30

Service Code	HCPCS J0185
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.66
Max. Negotiated Rate	$24.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.18
Rate for Payer: Aetna of CA Government/Medicare	$18.18
Rate for Payer: Cash Price	$16.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.24
Rate for Payer: Health Smart Auto/Commercial	$18.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.18
Rate for Payer: LLUH Dept of Risk Management WC	$16.66
Rate for Payer: Multiplan Commercial	$22.73

APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION [220348]

Facility

$30.30

Service Code	HCPCS J0185
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.66
Max. Negotiated Rate	$24.24
Rate for Payer: Cash Price	$16.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.24
Rate for Payer: Health Smart Auto/Commercial	$18.18
Rate for Payer: LLUH Dept of Risk Management WC	$16.66
Rate for Payer: Multiplan Commercial	$22.73

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$3.85

Service Code	NDC 0093-5955-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$2.89

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$3.85

Service Code	NDC 0093-5955-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.31
Rate for Payer: Aetna of CA Government/Medicare	$2.31
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$2.89

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$11.82

Service Code	NDC 63402-911-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$9.46
Rate for Payer: Cash Price	$6.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.46
Rate for Payer: Health Smart Auto/Commercial	$7.09
Rate for Payer: LLUH Dept of Risk Management WC	$6.50
Rate for Payer: Multiplan Commercial	$8.87

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$12.17

Service Code	NDC 27437-060-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.69
Max. Negotiated Rate	$9.74
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	$6.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.74
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 Commercial	$9.13

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$1.50

Service Code	NDC 69097-168-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$2.50

Service Code	NDC 62756-277-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.00
Rate for Payer: Cash Price	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.00
Rate for Payer: Health Smart Auto/Commercial	$1.50
Rate for Payer: LLUH Dept of Risk Management WC	$1.38
Rate for Payer: Multiplan Commercial	$1.88

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$3.85

Service Code	NDC 0093-5955-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$2.89

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$1.50

Service Code	NDC 69097-168-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$3.85

Service Code	NDC 0093-5955-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.31
Rate for Payer: Aetna of CA Government/Medicare	$2.31
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$2.89

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$11.82

Service Code	NDC 63402-911-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$9.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.09
Rate for Payer: Aetna of CA Government/Medicare	$7.09
Rate for Payer: Cash Price	$6.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.46
Rate for Payer: Health Smart Auto/Commercial	$7.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.09
Rate for Payer: LLUH Dept of Risk Management WC	$6.50
Rate for Payer: Multiplan Commercial	$8.87

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$3.85

Service Code	NDC 0093-5955-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.31
Rate for Payer: Aetna of CA Government/Medicare	$2.31
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$2.89

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$1.40

Service Code	NDC 70748-175-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$3.85

Service Code	NDC 0093-5955-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Cash Price	$2.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Commercial	$2.89

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$2.50

Service Code	NDC 62756-277-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.50
Rate for Payer: Aetna of CA Government/Medicare	$1.50
Rate for Payer: Cash Price	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.00
Rate for Payer: Health Smart Auto/Commercial	$1.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.50
Rate for Payer: LLUH Dept of Risk Management WC	$1.38
Rate for Payer: Multiplan Commercial	$1.88

ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]

Facility

$1.50

Service Code	NDC 69097-168-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

Know your out-of-pocket cost for care.

All Charges