Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$2.50

Service Code	NDC 45802-368-00
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

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$2.50

Service Code	NDC 45802-368-00
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

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$2.50

Service Code	NDC 45802-368-62
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

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$2.50

Service Code	NDC 45802-368-62
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

IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]

Facility

$57.84

Service Code	HCPCS J1559
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$31.81
Max. Negotiated Rate	$46.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$34.70
Rate for Payer: Aetna of CA Government/Medicare	$34.70
Rate for Payer: Cash Price	$31.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$46.27
Rate for Payer: Health Smart Auto/Commercial	$34.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$34.70
Rate for Payer: LLUH Dept of Risk Management WC	$31.81
Rate for Payer: Multiplan Commercial	$43.38

IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]

Facility

$57.84

Service Code	HCPCS J1559
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$31.81
Max. Negotiated Rate	$46.27
Rate for Payer: Cash Price	$31.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$46.27
Rate for Payer: Health Smart Auto/Commercial	$34.70
Rate for Payer: LLUH Dept of Risk Management WC	$31.81
Rate for Payer: Multiplan Commercial	$43.38

IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]

Facility

$17.85

Service Code	HCPCS J1561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$14.28
Rate for Payer: Cash Price	$9.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.28
Rate for Payer: Health Smart Auto/Commercial	$10.71
Rate for Payer: LLUH Dept of Risk Management WC	$9.82
Rate for Payer: Multiplan Commercial	$13.39

IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]

Facility

$17.85

Service Code	HCPCS J1561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$14.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.71
Rate for Payer: Aetna of CA Government/Medicare	$10.71
Rate for Payer: Cash Price	$9.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.28
Rate for Payer: Health Smart Auto/Commercial	$10.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.71
Rate for Payer: LLUH Dept of Risk Management WC	$9.82
Rate for Payer: Multiplan Commercial	$13.39

IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]

Facility

$17.85

Service Code	HCPCS J1561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$14.28
Rate for Payer: Cash Price	$9.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.28
Rate for Payer: Health Smart Auto/Commercial	$10.71
Rate for Payer: LLUH Dept of Risk Management WC	$9.82
Rate for Payer: Multiplan Commercial	$13.39

IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]

Facility

$17.85

Service Code	HCPCS J1561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$14.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.71
Rate for Payer: Aetna of CA Government/Medicare	$10.71
Rate for Payer: Cash Price	$9.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.28
Rate for Payer: Health Smart Auto/Commercial	$10.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.71
Rate for Payer: LLUH Dept of Risk Management WC	$9.82
Rate for Payer: Multiplan Commercial	$13.39

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$20.95

Service Code	HCPCS J1569
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$16.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.57
Rate for Payer: Aetna of CA Government/Medicare	$12.57
Rate for Payer: Cash Price	$11.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.76
Rate for Payer: Health Smart Auto/Commercial	$12.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.57
Rate for Payer: LLUH Dept of Risk Management WC	$11.52
Rate for Payer: Multiplan Commercial	$15.71

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$20.95

Service Code	HCPCS J1569
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$16.76
Rate for Payer: Cash Price	$11.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.76
Rate for Payer: Health Smart Auto/Commercial	$12.57
Rate for Payer: LLUH Dept of Risk Management WC	$11.52
Rate for Payer: Multiplan Commercial	$15.71

IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]

Facility

$23.31

Service Code	HCPCS J1568
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.82
Max. Negotiated Rate	$18.65
Rate for Payer: Cash Price	$12.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.65
Rate for Payer: Health Smart Auto/Commercial	$13.99
Rate for Payer: LLUH Dept of Risk Management WC	$12.82
Rate for Payer: Multiplan Commercial	$17.48

IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]

Facility

$23.31

Service Code	HCPCS J1568
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.82
Max. Negotiated Rate	$18.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.99
Rate for Payer: Aetna of CA Government/Medicare	$13.99
Rate for Payer: Cash Price	$12.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.65
Rate for Payer: Health Smart Auto/Commercial	$13.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.99
Rate for Payer: LLUH Dept of Risk Management WC	$12.82
Rate for Payer: Multiplan Commercial	$17.48

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$23.02

Service Code	HCPCS J1459
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$18.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.81
Rate for Payer: Aetna of CA Government/Medicare	$13.81
Rate for Payer: Cash Price	$12.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.42
Rate for Payer: Health Smart Auto/Commercial	$13.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.81
Rate for Payer: LLUH Dept of Risk Management WC	$12.66
Rate for Payer: Multiplan Commercial	$17.27

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$23.02

Service Code	HCPCS J1459
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$18.42
Rate for Payer: Cash Price	$12.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.42
Rate for Payer: Health Smart Auto/Commercial	$13.81
Rate for Payer: LLUH Dept of Risk Management WC	$12.66
Rate for Payer: Multiplan Commercial	$17.27

IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]

Facility

$11.65

Service Code	HCPCS J1568
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.41
Max. Negotiated Rate	$9.32
Rate for Payer: Cash Price	$6.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.32
Rate for Payer: Health Smart Auto/Commercial	$6.99
Rate for Payer: LLUH Dept of Risk Management WC	$6.41
Rate for Payer: Multiplan Commercial	$8.74

IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]

Facility

$11.65

Service Code	HCPCS J1568
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.41
Max. Negotiated Rate	$9.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.99
Rate for Payer: Aetna of CA Government/Medicare	$6.99
Rate for Payer: Cash Price	$6.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.32
Rate for Payer: Health Smart Auto/Commercial	$6.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.99
Rate for Payer: LLUH Dept of Risk Management WC	$6.41
Rate for Payer: Multiplan Commercial	$8.74

IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]

Facility

$17.85

Service Code	HCPCS J1561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$14.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.71
Rate for Payer: Aetna of CA Government/Medicare	$10.71
Rate for Payer: Cash Price	$9.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.28
Rate for Payer: Health Smart Auto/Commercial	$10.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.71
Rate for Payer: LLUH Dept of Risk Management WC	$9.82
Rate for Payer: Multiplan Commercial	$13.39

IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]

Facility

$17.85

Service Code	HCPCS J1561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$14.28
Rate for Payer: Cash Price	$9.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.28
Rate for Payer: Health Smart Auto/Commercial	$10.71
Rate for Payer: LLUH Dept of Risk Management WC	$9.82
Rate for Payer: Multiplan Commercial	$13.39

INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]

Facility

$613.20

Service Code	HCPCS J0588
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$337.26
Max. Negotiated Rate	$490.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$367.92
Rate for Payer: Aetna of CA Government/Medicare	$367.92
Rate for Payer: Cash Price	$337.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$490.56
Rate for Payer: Health Smart Auto/Commercial	$367.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$367.92
Rate for Payer: LLUH Dept of Risk Management WC	$337.26
Rate for Payer: Multiplan Commercial	$459.90

INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]

Facility

$613.20

Service Code	HCPCS J0588
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$337.26
Max. Negotiated Rate	$490.56
Rate for Payer: Cash Price	$337.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$490.56
Rate for Payer: Health Smart Auto/Commercial	$367.92
Rate for Payer: LLUH Dept of Risk Management WC	$337.26
Rate for Payer: Multiplan Commercial	$459.90

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]

Facility

$96.00

Service Code	HCPCS J9220
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.60
Rate for Payer: Aetna of CA Government/Medicare	$57.60
Rate for Payer: Cash Price	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Commercial	$72.00

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]

Facility

$96.00

Service Code	HCPCS J9220
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$76.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Commercial	$72.00

Know your out-of-pocket cost for care.

All Charges