Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$11.82

Service Code	NDC 63402-911-64
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

$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

$11.82

Service Code	NDC 63402-911-30
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

$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

$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

$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

$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

$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 0093-5955-56
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 62756-277-01
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

ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]

Facility

$244.80

Service Code	HCPCS J0883
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$134.64
Max. Negotiated Rate	$195.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$146.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.25
Rate for Payer: Aetna of CA Government/Medicare	$78.25
Rate for Payer: Aetna of CA Government/Medicare	$146.88
Rate for Payer: Cash Price	$71.73
Rate for Payer: Cash Price	$134.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$195.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$104.33
Rate for Payer: Health Smart Auto/Commercial	$146.88
Rate for Payer: Health Smart Auto/Commercial	$78.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$146.88
Rate for Payer: LLUH Dept of Risk Management WC	$71.73
Rate for Payer: LLUH Dept of Risk Management WC	$134.64
Rate for Payer: Multiplan Commercial	$183.60
Rate for Payer: Multiplan Commercial	$97.81

ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]

Facility

$130.41

Service Code	HCPCS J0883
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$71.73
Max. Negotiated Rate	$104.33
Rate for Payer: Cash Price	$71.73
Rate for Payer: Cash Price	$134.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$195.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$104.33
Rate for Payer: Health Smart Auto/Commercial	$78.25
Rate for Payer: Health Smart Auto/Commercial	$146.88
Rate for Payer: LLUH Dept of Risk Management WC	$71.73
Rate for Payer: LLUH Dept of Risk Management WC	$134.64
Rate for Payer: Multiplan Commercial	$97.81
Rate for Payer: Multiplan Commercial	$183.60

ARGININE 25 MG/ML-LYSINE 25 MG/ML IN 0.9 % NACL INTRAVENOUS SOLUTION [223945]

Facility

$0.45

Service Code	NDC 08252-0001-75
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

ARGININE 25 MG/ML-LYSINE 25 MG/ML IN 0.9 % NACL INTRAVENOUS SOLUTION [223945]

Facility

$0.45

Service Code	NDC 08252-0001-75
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT [220244]

Facility

$2.84

Service Code	NDC 5978166694
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Cash Price	$1.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Commercial	$2.13

ARGININE 7 GRAM-GLUTAM 7 GRAM-CAHMB 1.5 GRAM-COLLA-MV-MIN ORAL PWD PKT [220244]

Facility

$2.84

Service Code	NDC 5978166694
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.70
Rate for Payer: Aetna of CA Government/Medicare	$1.70
Rate for Payer: Cash Price	$1.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Commercial	$2.13

ARGININE HCL (L-ARGININE) 10 % CONTINUOUS INFUSION [203805]

Facility

$0.17

Service Code	NDC 0009-0436-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.13

ARGININE HCL (L-ARGININE) 10 % CONTINUOUS INFUSION [203805]

Facility

$0.17

Service Code	NDC 0009-0436-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
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	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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 Commercial	$0.13

ARGININE ORAL SOLN (IV FORM) 100 MG/ML (0.475 MEQ/ML) [4080420]

Facility

$0.16

Service Code	NDC 9994-0804-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

ARGININE ORAL SOLN (IV FORM) 100 MG/ML (0.475 MEQ/ML) [4080420]

Facility

$0.16

Service Code	NDC 9994-0804-20
Hospital Charge Code	901700029
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	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
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 Commercial	$0.12

ARIPIPRAZOLE 10 MG TABLET [34369]

Facility

$0.75

Service Code	NDC 50268-089-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ARIPIPRAZOLE 10 MG TABLET [34369]

Facility

$0.75

Service Code	NDC 50268-089-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ARIPIPRAZOLE 10 MG TABLET [34369]

Facility

$0.75

Service Code	NDC 50268-089-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ARIPIPRAZOLE 10 MG TABLET [34369]

Facility

$0.75

Service Code	NDC 50268-089-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

Know your out-of-pocket cost for care.

All Charges