Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IGG 5 GRAM/50 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207471]

Facility

$29.42

Service Code	NDC 0944-2511-02
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 5 GRAM/50 ML (10 %)-HYALURONIDASE,RECOMB. SUBCUTANEOUS SOLUTION [207471]

Facility

$29.42

Service Code	NDC 0944-2511-02
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

ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]

Facility

$179.92

Service Code	NDC 66215-302-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$143.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$107.95
Rate for Payer: Aetna of CA Government/Medicare	$107.95
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.94
Rate for Payer: Health Smart Auto/Commercial	$107.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$107.95
Rate for Payer: LLUH Dept of Risk Management WC	$98.96
Rate for Payer: Multiplan Commercial	$134.94

ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]

Facility

$179.90

Service Code	NDC 66215-302-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.94
Max. Negotiated Rate	$143.92
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.92
Rate for Payer: Health Smart Auto/Commercial	$107.94
Rate for Payer: LLUH Dept of Risk Management WC	$98.94
Rate for Payer: Multiplan Commercial	$134.93

ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]

Facility

$179.90

Service Code	NDC 66215-302-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.94
Max. Negotiated Rate	$143.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$107.94
Rate for Payer: Aetna of CA Government/Medicare	$107.94
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.92
Rate for Payer: Health Smart Auto/Commercial	$107.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$107.94
Rate for Payer: LLUH Dept of Risk Management WC	$98.94
Rate for Payer: Multiplan Commercial	$134.93

ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]

Facility

$179.92

Service Code	NDC 66215-302-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$143.94
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.94
Rate for Payer: Health Smart Auto/Commercial	$107.95
Rate for Payer: LLUH Dept of Risk Management WC	$98.96
Rate for Payer: Multiplan Commercial	$134.94

ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]

Facility

$179.92

Service Code	NDC 66215-303-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$143.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$107.95
Rate for Payer: Aetna of CA Government/Medicare	$107.95
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.94
Rate for Payer: Health Smart Auto/Commercial	$107.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$107.95
Rate for Payer: LLUH Dept of Risk Management WC	$98.96
Rate for Payer: Multiplan Commercial	$134.94

ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]

Facility

$179.90

Service Code	NDC 66215-303-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.94
Max. Negotiated Rate	$143.92
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.92
Rate for Payer: Health Smart Auto/Commercial	$107.94
Rate for Payer: LLUH Dept of Risk Management WC	$98.94
Rate for Payer: Multiplan Commercial	$134.93

ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]

Facility

$179.90

Service Code	NDC 66215-303-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.94
Max. Negotiated Rate	$143.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$107.94
Rate for Payer: Aetna of CA Government/Medicare	$107.94
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.92
Rate for Payer: Health Smart Auto/Commercial	$107.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$107.94
Rate for Payer: LLUH Dept of Risk Management WC	$98.94
Rate for Payer: Multiplan Commercial	$134.93

ILOPROST 20 MCG/ML SOLUTION FOR NEBULIZATION [99773]

Facility

$179.92

Service Code	NDC 66215-303-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$143.94
Rate for Payer: Cash Price	$98.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$143.94
Rate for Payer: Health Smart Auto/Commercial	$107.95
Rate for Payer: LLUH Dept of Risk Management WC	$98.96
Rate for Payer: Multiplan Commercial	$134.94

IMATINIB 100 MG TABLET [32979]

Facility

$1.97

Service Code	HCPCS S0088
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.73
Rate for Payer: Aetna of CA Government/Medicare	$1.18
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$2.73
Rate for Payer: Cash Price	$2.50
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cash Price	$1.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.64
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Commercial	$1.10
Rate for Payer: Multiplan Commercial	$1.48
Rate for Payer: Multiplan Commercial	$3.41

IMATINIB 100 MG TABLET [32979]

Facility

$1.97

Service Code	HCPCS S0088
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.58
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cash Price	$2.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Commercial	$1.48
Rate for Payer: Multiplan Commercial	$1.10
Rate for Payer: Multiplan Commercial	$3.41

IMATINIB 400 MG TABLET [36092]

Facility

$5.20

Service Code	HCPCS S0088
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$4.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.12
Rate for Payer: Aetna of CA Government/Medicare	$3.12
Rate for Payer: Cash Price	$2.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.16
Rate for Payer: Health Smart Auto/Commercial	$3.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.12
Rate for Payer: LLUH Dept of Risk Management WC	$2.86
Rate for Payer: Multiplan Commercial	$3.90

IMATINIB 400 MG TABLET [36092]

Facility

$5.20

Service Code	HCPCS S0088
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$2.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.16
Rate for Payer: Health Smart Auto/Commercial	$3.12
Rate for Payer: LLUH Dept of Risk Management WC	$2.86
Rate for Payer: Multiplan Commercial	$3.90

IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]

Facility

$20.51

Service Code	HCPCS J0743
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$16.41
Rate for Payer: Cash Price	$11.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.41
Rate for Payer: Health Smart Auto/Commercial	$12.31
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Commercial	$15.38

IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]

Facility

$20.51

Service Code	HCPCS J0743
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$16.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.31
Rate for Payer: Aetna of CA Government/Medicare	$12.31
Rate for Payer: Cash Price	$11.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.41
Rate for Payer: Health Smart Auto/Commercial	$12.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.31
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Commercial	$15.38

IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]

Facility

$32.82

Service Code	HCPCS J0743
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$26.26
Rate for Payer: Cash Price	$18.05
Rate for Payer: Cash Price	$19.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.78
Rate for Payer: Health Smart Auto/Commercial	$21.59
Rate for Payer: Health Smart Auto/Commercial	$19.69
Rate for Payer: LLUH Dept of Risk Management WC	$18.05
Rate for Payer: LLUH Dept of Risk Management WC	$19.79
Rate for Payer: Multiplan Commercial	$26.98
Rate for Payer: Multiplan Commercial	$24.61

IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]

Facility

$32.82

Service Code	HCPCS J0743
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$26.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.59
Rate for Payer: Aetna of CA Government/Medicare	$19.69
Rate for Payer: Aetna of CA Government/Medicare	$21.59
Rate for Payer: Cash Price	$18.05
Rate for Payer: Cash Price	$19.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.78
Rate for Payer: Health Smart Auto/Commercial	$19.69
Rate for Payer: Health Smart Auto/Commercial	$21.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.59
Rate for Payer: LLUH Dept of Risk Management WC	$19.79
Rate for Payer: LLUH Dept of Risk Management WC	$18.05
Rate for Payer: Multiplan Commercial	$24.61
Rate for Payer: Multiplan Commercial	$26.98

IMIPRAMINE 10 MG TABLET [3860]

Facility

$0.22

Service Code	NDC 69315-133-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

IMIPRAMINE 10 MG TABLET [3860]

Facility

$0.22

Service Code	NDC 69315-133-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

IMIPRAMINE 10 MG TABLET [3860]

Facility

$0.07

Service Code	NDC 69584-425-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

IMIPRAMINE 10 MG TABLET [3860]

Facility

$0.07

Service Code	NDC 69584-425-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

IMIPRAMINE 25 MG TABLET [3861]

Facility

$0.08

Service Code	NDC 69584-426-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

IMIPRAMINE 25 MG TABLET [3861]

Facility

$0.29

Service Code	NDC 69315-134-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

IMIPRAMINE 25 MG TABLET [3861]

Facility

$0.08

Service Code	NDC 69584-426-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

Know your out-of-pocket cost for care.

All Charges