Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.23

Service Code	NDC 60687-468-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.19

Service Code	NDC 59651-362-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.16

Service Code	NDC 64380-807-06
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

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.23

Service Code	NDC 60687-468-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.19

Service Code	NDC 59651-362-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.23

Service Code	NDC 60687-468-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
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	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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 Commercial	$0.17

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.09

Service Code	NDC 0904-5855-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.07

IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [76780]

Facility

$273.74

Service Code	HCPCS J1741
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$150.56
Max. Negotiated Rate	$218.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$164.24
Rate for Payer: Aetna of CA Government/Medicare	$164.24
Rate for Payer: Cash Price	$150.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$218.99
Rate for Payer: Health Smart Auto/Commercial	$164.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$164.24
Rate for Payer: LLUH Dept of Risk Management WC	$150.56
Rate for Payer: Multiplan Commercial	$205.31

IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [76780]

Facility

$273.74

Service Code	HCPCS J1741
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$150.56
Max. Negotiated Rate	$218.99
Rate for Payer: Cash Price	$150.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$218.99
Rate for Payer: Health Smart Auto/Commercial	$164.24
Rate for Payer: LLUH Dept of Risk Management WC	$150.56
Rate for Payer: Multiplan Commercial	$205.31

IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION [16156]

Facility

$67.18

Service Code	HCPCS J1742
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.95
Max. Negotiated Rate	$53.74
Rate for Payer: Cash Price	$36.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.74
Rate for Payer: Health Smart Auto/Commercial	$40.31
Rate for Payer: LLUH Dept of Risk Management WC	$36.95
Rate for Payer: Multiplan Commercial	$50.38

IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION [16156]

Facility

$67.18

Service Code	HCPCS J1742
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.95
Max. Negotiated Rate	$53.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.31
Rate for Payer: Aetna of CA Government/Medicare	$40.31
Rate for Payer: Cash Price	$36.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.74
Rate for Payer: Health Smart Auto/Commercial	$40.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.31
Rate for Payer: LLUH Dept of Risk Management WC	$36.95
Rate for Payer: Multiplan Commercial	$50.38

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$12.42

Service Code	HCPCS J9211
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$9.94
Rate for Payer: Cash Price	$6.83
Rate for Payer: Cash Price	$8.84
Rate for Payer: Cash Price	$7.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.35
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: Health Smart Auto/Commercial	$7.76
Rate for Payer: Health Smart Auto/Commercial	$7.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.83
Rate for Payer: LLUH Dept of Risk Management WC	$7.12
Rate for Payer: Multiplan Commercial	$12.05
Rate for Payer: Multiplan Commercial	$9.71
Rate for Payer: Multiplan Commercial	$9.31

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$16.07

Service Code	HCPCS J9211
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$12.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.76
Rate for Payer: Aetna of CA Government/Medicare	$7.45
Rate for Payer: Aetna of CA Government/Medicare	$7.76
Rate for Payer: Aetna of CA Government/Medicare	$9.64
Rate for Payer: Cash Price	$7.11
Rate for Payer: Cash Price	$6.83
Rate for Payer: Cash Price	$8.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.35
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: Health Smart Auto/Commercial	$7.76
Rate for Payer: Health Smart Auto/Commercial	$7.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.45
Rate for Payer: LLUH Dept of Risk Management WC	$6.83
Rate for Payer: LLUH Dept of Risk Management WC	$7.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Commercial	$9.71
Rate for Payer: Multiplan Commercial	$9.31
Rate for Payer: Multiplan Commercial	$12.05

IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [211698]

Facility

$61.23

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$48.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.74
Rate for Payer: Aetna of CA Government/Medicare	$36.74
Rate for Payer: Cash Price	$33.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.98
Rate for Payer: Health Smart Auto/Commercial	$36.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.74
Rate for Payer: LLUH Dept of Risk Management WC	$33.68
Rate for Payer: Multiplan Commercial	$45.92

IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [211698]

Facility

$61.23

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$48.98
Rate for Payer: Cash Price	$33.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.98
Rate for Payer: Health Smart Auto/Commercial	$36.74
Rate for Payer: LLUH Dept of Risk Management WC	$33.68
Rate for Payer: Multiplan Commercial	$45.92

IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION [87925]

Facility

$2.20

Service Code	HCPCS J9208
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.32
Rate for Payer: Aetna of CA Government/Medicare	$1.32
Rate for Payer: Cash Price	$1.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.76
Rate for Payer: Health Smart Auto/Commercial	$1.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.21
Rate for Payer: Multiplan Commercial	$1.65

IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION [87925]

Facility

$2.20

Service Code	HCPCS J9208
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.76
Rate for Payer: Cash Price	$1.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.76
Rate for Payer: Health Smart Auto/Commercial	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.21
Rate for Payer: Multiplan Commercial	$1.65

IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION [10248]

Facility

$44.09

Service Code	HCPCS J9208
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$24.25
Max. Negotiated Rate	$35.27
Rate for Payer: Cash Price	$24.25
Rate for Payer: Cash Price	$38.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$35.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.73
Rate for Payer: Health Smart Auto/Commercial	$26.45
Rate for Payer: Health Smart Auto/Commercial	$41.80
Rate for Payer: LLUH Dept of Risk Management WC	$38.31
Rate for Payer: LLUH Dept of Risk Management WC	$24.25
Rate for Payer: Multiplan Commercial	$33.07
Rate for Payer: Multiplan Commercial	$52.24

IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION [10248]

Facility

$44.09

Service Code	HCPCS J9208
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$24.25
Max. Negotiated Rate	$35.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$26.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.80
Rate for Payer: Aetna of CA Government/Medicare	$26.45
Rate for Payer: Aetna of CA Government/Medicare	$41.80
Rate for Payer: Cash Price	$24.25
Rate for Payer: Cash Price	$38.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$35.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.73
Rate for Payer: Health Smart Auto/Commercial	$26.45
Rate for Payer: Health Smart Auto/Commercial	$41.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$26.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.80
Rate for Payer: LLUH Dept of Risk Management WC	$38.31
Rate for Payer: LLUH Dept of Risk Management WC	$24.25
Rate for Payer: Multiplan Commercial	$33.07
Rate for Payer: Multiplan Commercial	$52.24

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$129.05

Service Code	HCPCS J9208
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$103.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$77.43
Rate for Payer: Aetna of CA Government/Medicare	$77.43
Rate for Payer: Cash Price	$70.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$103.24
Rate for Payer: Health Smart Auto/Commercial	$77.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$77.43
Rate for Payer: LLUH Dept of Risk Management WC	$70.98
Rate for Payer: Multiplan Commercial	$96.79

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$129.05

Service Code	HCPCS J9208
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$103.24
Rate for Payer: Cash Price	$70.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$103.24
Rate for Payer: Health Smart Auto/Commercial	$77.43
Rate for Payer: LLUH Dept of Risk Management WC	$70.98
Rate for Payer: Multiplan Commercial	$96.79

IGG 10 GRAM/100 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207472]

Facility

$29.42

Service Code	NDC 0944-2512-02
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$23.54
Rate for Payer: Cash Price	$16.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.54
Rate for Payer: Health Smart Auto/Commercial	$17.65
Rate for Payer: LLUH Dept of Risk Management WC	$16.18
Rate for Payer: Multiplan Commercial	$22.07

IGG 10 GRAM/100 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207472]

Facility

$29.42

Service Code	NDC 0944-2512-02
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$23.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.65
Rate for Payer: Aetna of CA Government/Medicare	$17.65
Rate for Payer: Cash Price	$16.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.54
Rate for Payer: Health Smart Auto/Commercial	$17.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.65
Rate for Payer: LLUH Dept of Risk Management WC	$16.18
Rate for Payer: Multiplan Commercial	$22.07

IGG 20 GRAM/200 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207473]

Facility

$29.42

Service Code	NDC 0944-2513-02
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$23.54
Rate for Payer: Cash Price	$16.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.54
Rate for Payer: Health Smart Auto/Commercial	$17.65
Rate for Payer: LLUH Dept of Risk Management WC	$16.18
Rate for Payer: Multiplan Commercial	$22.07

IGG 20 GRAM/200 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207473]

Facility

$29.42

Service Code	NDC 0944-2513-02
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$23.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.65
Rate for Payer: Aetna of CA Government/Medicare	$17.65
Rate for Payer: Cash Price	$16.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.54
Rate for Payer: Health Smart Auto/Commercial	$17.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.65
Rate for Payer: LLUH Dept of Risk Management WC	$16.18
Rate for Payer: Multiplan Commercial	$22.07

Know your out-of-pocket cost for care.

All Charges