Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]

Facility

$18.00

Service Code	HCPCS J9017
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.29
Rate for Payer: Aetna of CA Government/Medicare	$27.29
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$25.02
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.39
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$27.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.29
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: LLUH Dept of Risk Management WC	$25.02
Rate for Payer: Multiplan Commercial	$34.12
Rate for Payer: Multiplan Commercial	$13.50

ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION [220455]

Facility

$255.26

Service Code	HCPCS J9017
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$140.39
Max. Negotiated Rate	$204.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$153.16
Rate for Payer: Aetna of CA Government/Medicare	$153.16
Rate for Payer: Cash Price	$140.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.21
Rate for Payer: Health Smart Auto/Commercial	$153.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$153.16
Rate for Payer: LLUH Dept of Risk Management WC	$140.39
Rate for Payer: Multiplan Commercial	$191.44

ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION [220455]

Facility

$255.26

Service Code	HCPCS J9017
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$140.39
Max. Negotiated Rate	$204.21
Rate for Payer: Cash Price	$140.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.21
Rate for Payer: Health Smart Auto/Commercial	$153.16
Rate for Payer: LLUH Dept of Risk Management WC	$140.39
Rate for Payer: Multiplan Commercial	$191.44

ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET [96948]

Facility

$6.74

Service Code	NDC 0078-0568-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$5.39
Rate for Payer: Cash Price	$3.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.39
Rate for Payer: Health Smart Auto/Commercial	$4.04
Rate for Payer: LLUH Dept of Risk Management WC	$3.71
Rate for Payer: Multiplan Commercial	$5.05

ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET [96948]

Facility

$6.74

Service Code	NDC 0078-0568-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$5.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.04
Rate for Payer: Aetna of CA Government/Medicare	$4.04
Rate for Payer: Cash Price	$3.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.39
Rate for Payer: Health Smart Auto/Commercial	$4.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.04
Rate for Payer: LLUH Dept of Risk Management WC	$3.71
Rate for Payer: Multiplan Commercial	$5.05

ARTIFICIAL TEARS(DEXTRAN-HYPROMEL-GLYCERN) 0.1 %-0.3 %-0.2 % EYE DROPS [114932]

Facility

$0.53

Service Code	NDC 0065-0426-36
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

ARTIFICIAL TEARS(DEXTRAN-HYPROMEL-GLYCERN) 0.1 %-0.3 %-0.2 % EYE DROPS [114932]

Facility

$0.53

Service Code	NDC 0065-0426-36
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
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: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$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: Multiplan Commercial	$0.40

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.51

Service Code	NDC 7430001067
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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 Commercial	$0.11

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.14

Service Code	NDC 57896-184-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.14

Service Code	NDC 57896-184-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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 Commercial	$0.11

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.51

Service Code	NDC 7430001067
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.67

Service Code	NDC 0023-0798-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
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	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
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	$0.37
Rate for Payer: Multiplan Commercial	$0.50

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.64

Service Code	NDC 50268-068-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.64

Service Code	NDC 50268-068-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.67

Service Code	NDC 0023-0798-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$3.35

Service Code	NDC 0023-0312-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.68
Rate for Payer: Cash Price	$1.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.68
Rate for Payer: Health Smart Auto/Commercial	$2.01
Rate for Payer: LLUH Dept of Risk Management WC	$1.84
Rate for Payer: Multiplan Commercial	$2.51

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.52

Service Code	NDC 1011902239
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.51
Rate for Payer: Aetna of CA Government/Medicare	$1.51
Rate for Payer: Cash Price	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.02
Rate for Payer: Health Smart Auto/Commercial	$1.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.51
Rate for Payer: LLUH Dept of Risk Management WC	$1.39
Rate for Payer: Multiplan Commercial	$1.89

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.34

Service Code	NDC 9999-9022-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.75

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.52

Service Code	NDC 1011902239
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.02
Rate for Payer: Cash Price	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.02
Rate for Payer: Health Smart Auto/Commercial	$1.51
Rate for Payer: LLUH Dept of Risk Management WC	$1.39
Rate for Payer: Multiplan Commercial	$1.89

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$1.85

Service Code	NDC 0904-6488-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.11
Rate for Payer: Aetna of CA Government/Medicare	$1.11
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$3.35

Service Code	NDC 0023-0312-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.01
Rate for Payer: Aetna of CA Government/Medicare	$2.01
Rate for Payer: Cash Price	$1.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.68
Rate for Payer: Health Smart Auto/Commercial	$2.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.01
Rate for Payer: LLUH Dept of Risk Management WC	$1.84
Rate for Payer: Multiplan Commercial	$2.51

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.34

Service Code	NDC 9999-9022-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.75

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$1.85

Service Code	NDC 0904-6488-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

Know your out-of-pocket cost for care.

All Charges