Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$6.74

Service Code	NDC 0078-0568-45
Hospital Charge Code	1712541
Hospital Revenue Code	259
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$5.39
Rate for Payer: Cash Price	$3.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$5.06

ARTESUNATE 110 MG INTRAVENOUS SOLUTION [230847]

Facility

$5,976.00

Service Code	CPT J3490
Hospital Charge Code	ERX230847
Hospital Revenue Code	636
Min. Negotiated Rate	$3,286.80
Max. Negotiated Rate	$4,482.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,585.60
Rate for Payer: Aetna of CA Government/Medicare	$3,585.60
Rate for Payer: Cash Price	$2,689.20
Rate for Payer: Health Smart Auto/Commercial	$3,585.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,585.60
Rate for Payer: LLUH Dept of Risk Management WC	$3,286.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,482.00

ARTESUNATE 110 MG INTRAVENOUS SOLUTION [230847]

Facility

$5,976.00

Service Code	CPT J3490
Hospital Charge Code	ERX230847
Hospital Revenue Code	636
Min. Negotiated Rate	$3,286.80
Max. Negotiated Rate	$4,780.80
Rate for Payer: Cash Price	$2,689.20
Rate for Payer: Cigna of CA HMO/PPO	$4,780.80
Rate for Payer: Health Smart Auto/Commercial	$3,585.60
Rate for Payer: LLUH Dept of Risk Management WC	$3,286.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,482.00

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.42

Service Code	NDC 7430001067
Hospital Charge Code	NDG232731
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$2.27

Service Code	NDC 0998-0408-15
Hospital Charge Code	1740176
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$2.27

Service Code	NDC 0998-0408-15
Hospital Charge Code	1740176
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cigna of CA HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	NDG41412
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	$0.06
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

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	NDG41412
Hospital Revenue Code	259
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

ARTIFICIAL TEARS EYE DROPS. [40820640]

Facility

$0.42

Service Code	NDC 7430001067
Hospital Charge Code	NDG232731
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.34

Service Code	NDC 9999-9022-39
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.76
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	$1.05
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 Beech St/Commercial/PHCS	$1.76

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$1.85

Service Code	NDC 0904-6488-38
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.39
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	$0.83
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 Beech St/Commercial/PHCS	$1.39

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.34

Service Code	NDC 1011902239
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.76

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$3.35

Service Code	NDC 0023-0312-04
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.68
Rate for Payer: Cash Price	$1.51
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.51

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$3.35

Service Code	NDC 0023-0312-04
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.51
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	$1.51
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 Beech St/Commercial/PHCS	$2.51

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$1.85

Service Code	NDC 0904-6488-38
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$0.83
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.39

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.34

Service Code	NDC 1011902239
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.76
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	$1.05
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 Beech St/Commercial/PHCS	$1.76

ARTIFICIAL TEARS EYE OINTMENT [408111170]

Facility

$2.34

Service Code	NDC 9999-9022-39
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.76

ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]

Facility

$0.86

Service Code	NDC 0065-8064-01
Hospital Charge Code	1740326
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]

Facility

$0.86

Service Code	NDC 0065-8064-01
Hospital Charge Code	1740326
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

ARTIFICIAL TEARS (HYPROMELLOSE) 0.5 % EYE DROPS [27980]

Facility

$2.27

Service Code	NDC 0998-0408-15
Hospital Charge Code	1740176
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

ARTIFICIAL TEARS (HYPROMELLOSE) 0.5 % EYE DROPS [27980]

Facility

$2.27

Service Code	NDC 0998-0408-15
Hospital Charge Code	1740176
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cigna of CA HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

ASCIMINIB 20 MG TABLET [233024]

Facility

$402.11

Service Code	NDC 0078-1091-20
Hospital Charge Code	ERX233024
Hospital Revenue Code	259
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$321.69
Rate for Payer: Cash Price	$180.95
Rate for Payer: Cigna of CA HMO/PPO	$321.69
Rate for Payer: Health Smart Auto/Commercial	$241.27
Rate for Payer: LLUH Dept of Risk Management WC	$221.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$301.58

ASCIMINIB 20 MG TABLET [233024]

Facility

$402.11

Service Code	NDC 0078-1091-20
Hospital Charge Code	ERX233024
Hospital Revenue Code	259
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$301.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$241.27
Rate for Payer: Aetna of CA Government/Medicare	$241.27
Rate for Payer: Cash Price	$180.95
Rate for Payer: Health Smart Auto/Commercial	$241.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$241.27
Rate for Payer: LLUH Dept of Risk Management WC	$221.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$301.58

ASCIMINIB 40 MG TABLET [233025]

Facility

$402.11

Service Code	NDC 0078-1098-20
Hospital Charge Code	ERX233025
Hospital Revenue Code	259
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$321.69
Rate for Payer: Cash Price	$180.95
Rate for Payer: Cigna of CA HMO/PPO	$321.69
Rate for Payer: Health Smart Auto/Commercial	$241.27
Rate for Payer: LLUH Dept of Risk Management WC	$221.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$301.58

ASCIMINIB 40 MG TABLET [233025]

Facility

$402.11

Service Code	NDC 0078-1098-20
Hospital Charge Code	ERX233025
Hospital Revenue Code	259
Min. Negotiated Rate	$221.16
Max. Negotiated Rate	$301.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$241.27
Rate for Payer: Aetna of CA Government/Medicare	$241.27
Rate for Payer: Cash Price	$180.95
Rate for Payer: Health Smart Auto/Commercial	$241.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$241.27
Rate for Payer: LLUH Dept of Risk Management WC	$221.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$301.58

Know your out-of-pocket cost for care.

All Charges