Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$343.00

Service Code	NDC 70100-725-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$274.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$205.80
Rate for Payer: Aetna of CA Government/Medicare	$205.80
Rate for Payer: Cash Price	$188.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$274.40
Rate for Payer: Health Smart Auto/Commercial	$205.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$205.80
Rate for Payer: LLUH Dept of Risk Management WC	$188.65
Rate for Payer: Multiplan Commercial	$257.25

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$343.00

Service Code	NDC 70100-825-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$274.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$205.80
Rate for Payer: Aetna of CA Government/Medicare	$205.80
Rate for Payer: Cash Price	$188.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$274.40
Rate for Payer: Health Smart Auto/Commercial	$205.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$205.80
Rate for Payer: LLUH Dept of Risk Management WC	$188.65
Rate for Payer: Multiplan Commercial	$257.25

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$343.00

Service Code	NDC 70100-825-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$274.40
Rate for Payer: Cash Price	$188.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$274.40
Rate for Payer: Health Smart Auto/Commercial	$205.80
Rate for Payer: LLUH Dept of Risk Management WC	$188.65
Rate for Payer: Multiplan Commercial	$257.25

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$343.00

Service Code	NDC 70100-725-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$274.40
Rate for Payer: Cash Price	$188.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$274.40
Rate for Payer: Health Smart Auto/Commercial	$205.80
Rate for Payer: LLUH Dept of Risk Management WC	$188.65
Rate for Payer: Multiplan Commercial	$257.25

INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]

Facility

$445.49

Service Code	NDC 63323-659-94
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$245.02
Max. Negotiated Rate	$356.39
Rate for Payer: Cash Price	$245.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$356.39
Rate for Payer: Health Smart Auto/Commercial	$267.29
Rate for Payer: LLUH Dept of Risk Management WC	$245.02
Rate for Payer: Multiplan Commercial	$334.12

INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]

Facility

$445.49

Service Code	NDC 63323-659-94
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$245.02
Max. Negotiated Rate	$356.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$267.29
Rate for Payer: Aetna of CA Government/Medicare	$267.29
Rate for Payer: Cash Price	$245.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$356.39
Rate for Payer: Health Smart Auto/Commercial	$267.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$267.29
Rate for Payer: LLUH Dept of Risk Management WC	$245.02
Rate for Payer: Multiplan Commercial	$334.12

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.26

Service Code	NDC 68462-406-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.26

Service Code	NDC 68462-406-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.39

Service Code	NDC 50268-431-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.33

Service Code	NDC 68462-302-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.39

Service Code	NDC 50268-431-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.33

Service Code	NDC 68462-302-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$434.29

Service Code	NDC 69344-102-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$238.86
Max. Negotiated Rate	$347.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$260.57
Rate for Payer: Aetna of CA Government/Medicare	$260.57
Rate for Payer: Cash Price	$238.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.43
Rate for Payer: Health Smart Auto/Commercial	$260.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$260.57
Rate for Payer: LLUH Dept of Risk Management WC	$238.86
Rate for Payer: Multiplan Commercial	$325.72

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$434.29

Service Code	NDC 69344-102-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$238.86
Max. Negotiated Rate	$347.43
Rate for Payer: Cash Price	$238.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.43
Rate for Payer: Health Smart Auto/Commercial	$260.57
Rate for Payer: LLUH Dept of Risk Management WC	$238.86
Rate for Payer: Multiplan Commercial	$325.72

INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]

Facility

$0.42

Service Code	NDC 68462-325-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.32

INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]

Facility

$0.42

Service Code	NDC 68462-325-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
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	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
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 Commercial	$0.32

INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]

Facility

$570.00

Service Code	HCPCS J1745
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$313.50
Max. Negotiated Rate	$456.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$342.00
Rate for Payer: Aetna of CA Government/Medicare	$342.00
Rate for Payer: Cash Price	$313.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$456.00
Rate for Payer: Health Smart Auto/Commercial	$342.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$342.00
Rate for Payer: LLUH Dept of Risk Management WC	$313.50
Rate for Payer: Multiplan Commercial	$427.50

INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]

Facility

$570.00

Service Code	HCPCS J1745
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$313.50
Max. Negotiated Rate	$456.00
Rate for Payer: Cash Price	$313.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$456.00
Rate for Payer: Health Smart Auto/Commercial	$342.00
Rate for Payer: LLUH Dept of Risk Management WC	$313.50
Rate for Payer: Multiplan Commercial	$427.50

INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]

Facility

$904.07

Service Code	HCPCS Q5104
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$497.24
Max. Negotiated Rate	$723.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$542.44
Rate for Payer: Aetna of CA Government/Medicare	$542.44
Rate for Payer: Cash Price	$497.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$723.26
Rate for Payer: Health Smart Auto/Commercial	$542.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$542.44
Rate for Payer: LLUH Dept of Risk Management WC	$497.24
Rate for Payer: Multiplan Commercial	$678.05

INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]

Facility

$904.07

Service Code	HCPCS Q5104
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$497.24
Max. Negotiated Rate	$723.26
Rate for Payer: Cash Price	$497.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$723.26
Rate for Payer: Health Smart Auto/Commercial	$542.44
Rate for Payer: LLUH Dept of Risk Management WC	$497.24
Rate for Payer: Multiplan Commercial	$678.05

Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code

Facility

$1,112.00

Service Code	HCPCS H0010
Hospital Revenue Code	136
Min. Negotiated Rate	$1,112.00
Max. Negotiated Rate	$1,112.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,112.00

Know your out-of-pocket cost for care.

All Charges