Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS [211718]

Facility

$357.48

Service Code	HCPCS J9205
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$196.61
Max. Negotiated Rate	$285.98
Rate for Payer: Cash Price	$196.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$285.98
Rate for Payer: Health Smart Auto/Commercial	$214.49
Rate for Payer: LLUH Dept of Risk Management WC	$196.61
Rate for Payer: Multiplan Commercial	$268.11

IRON, CARBONYL 45 MG TABLET [33267]

Facility

$0.17

Service Code	NDC 4601709660
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
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	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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	$0.13

IRON, CARBONYL 45 MG TABLET [33267]

Facility

$0.17

Service Code	NDC 4601709660
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

IRON DEXTRAN 50 MG/ML INJECTION SOLUTION [221652]

Facility

$22.37

Service Code	HCPCS J1750
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.30
Max. Negotiated Rate	$17.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.42
Rate for Payer: Aetna of CA Government/Medicare	$13.42
Rate for Payer: Cash Price	$12.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.90
Rate for Payer: Health Smart Auto/Commercial	$13.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.42
Rate for Payer: LLUH Dept of Risk Management WC	$12.30
Rate for Payer: Multiplan Commercial	$16.78

IRON DEXTRAN 50 MG/ML INJECTION SOLUTION [221652]

Facility

$22.37

Service Code	HCPCS J1750
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.30
Max. Negotiated Rate	$17.90
Rate for Payer: Cash Price	$12.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.90
Rate for Payer: Health Smart Auto/Commercial	$13.42
Rate for Payer: LLUH Dept of Risk Management WC	$12.30
Rate for Payer: Multiplan Commercial	$16.78

IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]

Facility

$7.06

Service Code	HCPCS J1756
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$5.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.35
Rate for Payer: Aetna of CA Government/Medicare	$4.24
Rate for Payer: Aetna of CA Government/Medicare	$9.35
Rate for Payer: Cash Price	$3.88
Rate for Payer: Cash Price	$8.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.47
Rate for Payer: Health Smart Auto/Commercial	$9.35
Rate for Payer: Health Smart Auto/Commercial	$4.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.24
Rate for Payer: LLUH Dept of Risk Management WC	$3.88
Rate for Payer: LLUH Dept of Risk Management WC	$8.57
Rate for Payer: Multiplan Commercial	$5.29
Rate for Payer: Multiplan Commercial	$11.69

IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]

Facility

$7.06

Service Code	HCPCS J1756
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$5.65
Rate for Payer: Cash Price	$3.88
Rate for Payer: Cash Price	$8.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.65
Rate for Payer: Health Smart Auto/Commercial	$9.35
Rate for Payer: Health Smart Auto/Commercial	$4.24
Rate for Payer: LLUH Dept of Risk Management WC	$3.88
Rate for Payer: LLUH Dept of Risk Management WC	$8.57
Rate for Payer: Multiplan Commercial	$11.69
Rate for Payer: Multiplan Commercial	$5.29

IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION [187493]

Facility

$14.69

Service Code	HCPCS J1756
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.75
Rate for Payer: Cash Price	$8.08
Rate for Payer: Cash Price	$8.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.75
Rate for Payer: Health Smart Auto/Commercial	$8.81
Rate for Payer: Health Smart Auto/Commercial	$9.35
Rate for Payer: LLUH Dept of Risk Management WC	$8.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.57
Rate for Payer: Multiplan Commercial	$11.69
Rate for Payer: Multiplan Commercial	$11.02

IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION [187493]

Facility

$14.69

Service Code	HCPCS J1756
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.35
Rate for Payer: Aetna of CA Government/Medicare	$8.81
Rate for Payer: Aetna of CA Government/Medicare	$9.35
Rate for Payer: Cash Price	$8.08
Rate for Payer: Cash Price	$8.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.47
Rate for Payer: Health Smart Auto/Commercial	$8.81
Rate for Payer: Health Smart Auto/Commercial	$9.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.35
Rate for Payer: LLUH Dept of Risk Management WC	$8.57
Rate for Payer: LLUH Dept of Risk Management WC	$8.08
Rate for Payer: Multiplan Commercial	$11.02
Rate for Payer: Multiplan Commercial	$11.69

IRON SUCROSE 50 MG IRON/2.5 ML INTRAVENOUS SOLUTION [121793]

Facility

$14.69

Service Code	HCPCS J1756
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.75
Rate for Payer: Cash Price	$8.08
Rate for Payer: Cash Price	$8.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.75
Rate for Payer: Health Smart Auto/Commercial	$8.81
Rate for Payer: Health Smart Auto/Commercial	$9.35
Rate for Payer: LLUH Dept of Risk Management WC	$8.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.57
Rate for Payer: Multiplan Commercial	$11.02
Rate for Payer: Multiplan Commercial	$11.69

IRON SUCROSE 50 MG IRON/2.5 ML INTRAVENOUS SOLUTION [121793]

Facility

$15.59

Service Code	HCPCS J1756
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$12.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.81
Rate for Payer: Aetna of CA Government/Medicare	$9.35
Rate for Payer: Aetna of CA Government/Medicare	$8.81
Rate for Payer: Cash Price	$8.57
Rate for Payer: Cash Price	$8.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.75
Rate for Payer: Health Smart Auto/Commercial	$8.81
Rate for Payer: Health Smart Auto/Commercial	$9.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.81
Rate for Payer: LLUH Dept of Risk Management WC	$8.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.57
Rate for Payer: Multiplan Commercial	$11.69
Rate for Payer: Multiplan Commercial	$11.02

ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]

Facility

$208.78

Service Code	HCPCS J9227
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$114.83
Max. Negotiated Rate	$167.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$125.27
Rate for Payer: Aetna of CA Government/Medicare	$125.27
Rate for Payer: Cash Price	$114.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$167.02
Rate for Payer: Health Smart Auto/Commercial	$125.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$125.27
Rate for Payer: LLUH Dept of Risk Management WC	$114.83
Rate for Payer: Multiplan Commercial	$156.59

ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [227445]

Facility

$208.78

Service Code	HCPCS J9227
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$114.83
Max. Negotiated Rate	$167.02
Rate for Payer: Cash Price	$114.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$167.02
Rate for Payer: Health Smart Auto/Commercial	$125.27
Rate for Payer: LLUH Dept of Risk Management WC	$114.83
Rate for Payer: Multiplan Commercial	$156.59

ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]

Facility

$138.90

Service Code	NDC 0469-0520-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$76.39
Max. Negotiated Rate	$111.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$83.34
Rate for Payer: Aetna of CA Government/Medicare	$83.34
Rate for Payer: Cash Price	$76.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.12
Rate for Payer: Health Smart Auto/Commercial	$83.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$83.34
Rate for Payer: LLUH Dept of Risk Management WC	$76.39
Rate for Payer: Multiplan Commercial	$104.17

ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]

Facility

$138.90

Service Code	NDC 0469-0520-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$76.39
Max. Negotiated Rate	$111.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$83.34
Rate for Payer: Aetna of CA Government/Medicare	$83.34
Rate for Payer: Cash Price	$76.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.12
Rate for Payer: Health Smart Auto/Commercial	$83.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$83.34
Rate for Payer: LLUH Dept of Risk Management WC	$76.39
Rate for Payer: Multiplan Commercial	$104.17

ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]

Facility

$138.90

Service Code	NDC 0469-0520-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$76.39
Max. Negotiated Rate	$111.12
Rate for Payer: Cash Price	$76.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.12
Rate for Payer: Health Smart Auto/Commercial	$83.34
Rate for Payer: LLUH Dept of Risk Management WC	$76.39
Rate for Payer: Multiplan Commercial	$104.17

ISAVUCONAZONIUM SULFATE 186 MG CAPSULE [209331]

Facility

$138.90

Service Code	NDC 0469-0520-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$76.39
Max. Negotiated Rate	$111.12
Rate for Payer: Cash Price	$76.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.12
Rate for Payer: Health Smart Auto/Commercial	$83.34
Rate for Payer: LLUH Dept of Risk Management WC	$76.39
Rate for Payer: Multiplan Commercial	$104.17

ISAVUCONAZONIUM SULFATE 372 MG INTRAVENOUS SOLUTION [209328]

Facility

$473.26

Service Code	HCPCS J1833
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$260.29
Max. Negotiated Rate	$378.61
Rate for Payer: Cash Price	$260.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$378.61
Rate for Payer: Health Smart Auto/Commercial	$283.96
Rate for Payer: LLUH Dept of Risk Management WC	$260.29
Rate for Payer: Multiplan Commercial	$354.94

ISAVUCONAZONIUM SULFATE 372 MG INTRAVENOUS SOLUTION [209328]

Facility

$473.26

Service Code	HCPCS J1833
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$260.29
Max. Negotiated Rate	$378.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$283.96
Rate for Payer: Aetna of CA Government/Medicare	$283.96
Rate for Payer: Cash Price	$260.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$378.61
Rate for Payer: Health Smart Auto/Commercial	$283.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$283.96
Rate for Payer: LLUH Dept of Risk Management WC	$260.29
Rate for Payer: Multiplan Commercial	$354.94

ISONIAZID 100 MG TABLET [4026]

Facility

$2.14

Service Code	NDC 64950-216-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.71
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.71
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.18
Rate for Payer: Multiplan Commercial	$1.60

ISONIAZID 100 MG TABLET [4026]

Facility

$2.14

Service Code	NDC 64950-216-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.71
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.18
Rate for Payer: Multiplan Commercial	$1.60

ISONIAZID 100 MG TABLET [4026]

Facility

$0.14

Service Code	NDC 0555-0066-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

ISONIAZID 100 MG TABLET [4026]

Facility

$0.14

Service Code	NDC 0555-0066-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

ISONIAZID 300 MG TABLET [4027]

Facility

$4.20

Service Code	NDC 64950-217-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

ISONIAZID 300 MG TABLET [4027]

Facility

$4.20

Service Code	NDC 64950-217-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

Know your out-of-pocket cost for care.

All Charges