Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]

Facility

$5.31

Service Code	HCPCS Q9966
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.92
Rate for Payer: Cash Price	$4.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: Multiplan Commercial	$3.98
Rate for Payer: Multiplan Commercial	$5.82

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]

Facility

$6.87

Service Code	NDC 0270-1412-15
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$5.50
Rate for Payer: Cash Price	$3.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.50
Rate for Payer: Health Smart Auto/Commercial	$4.12
Rate for Payer: LLUH Dept of Risk Management WC	$3.78
Rate for Payer: Multiplan Commercial	$5.15

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]

Facility

$6.87

Service Code	NDC 0270-1412-15
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$5.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.12
Rate for Payer: Aetna of CA Government/Medicare	$4.12
Rate for Payer: Cash Price	$3.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.50
Rate for Payer: Health Smart Auto/Commercial	$4.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.12
Rate for Payer: LLUH Dept of Risk Management WC	$3.78
Rate for Payer: Multiplan Commercial	$5.15

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]

Facility

$0.88

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66
Rate for Payer: Multiplan Commercial	$0.41

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]

Facility

$0.55

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.41
Rate for Payer: Multiplan Commercial	$0.66

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]

Facility

$0.61

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]

Facility

$0.61

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]

Facility

$7.76

Service Code	HCPCS Q9966
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$6.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$4.66
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.92
Rate for Payer: Cash Price	$4.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.21
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: Multiplan Commercial	$3.98
Rate for Payer: Multiplan Commercial	$5.82

IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]

Facility

$5.31

Service Code	HCPCS Q9966
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.92
Rate for Payer: Cash Price	$4.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.21
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98
Rate for Payer: Multiplan Commercial	$5.82

IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]

Facility

$0.58

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]

Facility

$0.58

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]

Facility

$0.56

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42
Rate for Payer: Multiplan Commercial	$0.46

IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]

Facility

$0.56

Service Code	HCPCS Q9967
Hospital Charge Code	901700042
Hospital Revenue Code	254
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42
Rate for Payer: Multiplan Commercial	$0.46

IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]

Facility

$0.29

Service Code	HCPCS Q9961
Hospital Charge Code	901700036
Hospital Revenue Code	255
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 EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37
Rate for Payer: Multiplan Commercial	$0.22

IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]

Facility

$0.49

Service Code	HCPCS Q9961
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.22
Rate for Payer: Multiplan Commercial	$0.37

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.20

Service Code	NDC 0378-9671-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.20

Service Code	NDC 0378-9671-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.26

Service Code	NDC 60687-405-83
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	$0.14
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

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.26

Service Code	NDC 60687-405-79
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	$0.14
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

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.20

Service Code	NDC 0378-9671-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.20

Service Code	NDC 0378-9671-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.26

Service Code	NDC 60687-405-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
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

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]

Facility

$0.26

Service Code	NDC 60687-405-79
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
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

IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION [207748]

Facility

$151.21

Service Code	NDC 0597-0024-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$83.17
Max. Negotiated Rate	$120.97
Rate for Payer: Cash Price	$83.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.97
Rate for Payer: Health Smart Auto/Commercial	$90.73
Rate for Payer: LLUH Dept of Risk Management WC	$83.17
Rate for Payer: Multiplan Commercial	$113.41

IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION [207748]

Facility

$151.21

Service Code	NDC 0597-0024-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$83.17
Max. Negotiated Rate	$120.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.73
Rate for Payer: Aetna of CA Government/Medicare	$90.73
Rate for Payer: Cash Price	$83.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.97
Rate for Payer: Health Smart Auto/Commercial	$90.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.73
Rate for Payer: LLUH Dept of Risk Management WC	$83.17
Rate for Payer: Multiplan Commercial	$113.41

Know your out-of-pocket cost for care.

All Charges