Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]

Facility

$0.09

Service Code	NDC 50742-176-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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	$0.07
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	$0.05
Rate for Payer: Multiplan Commercial	$0.07

ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]

Facility

$150.96

Service Code	HCPCS Q9968
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$83.03
Max. Negotiated Rate	$120.77
Rate for Payer: Cash Price	$83.03
Rate for Payer: Cash Price	$160.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$233.12
Rate for Payer: Health Smart Auto/Commercial	$90.58
Rate for Payer: Health Smart Auto/Commercial	$174.84
Rate for Payer: LLUH Dept of Risk Management WC	$160.27
Rate for Payer: LLUH Dept of Risk Management WC	$83.03
Rate for Payer: Multiplan Commercial	$113.22
Rate for Payer: Multiplan Commercial	$218.55

ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]

Facility

$150.96

Service Code	HCPCS Q9968
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$83.03
Max. Negotiated Rate	$120.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$174.84
Rate for Payer: Aetna of CA Government/Medicare	$174.84
Rate for Payer: Aetna of CA Government/Medicare	$90.58
Rate for Payer: Cash Price	$160.27
Rate for Payer: Cash Price	$83.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$233.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.77
Rate for Payer: Health Smart Auto/Commercial	$90.58
Rate for Payer: Health Smart Auto/Commercial	$174.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$174.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.58
Rate for Payer: LLUH Dept of Risk Management WC	$160.27
Rate for Payer: LLUH Dept of Risk Management WC	$83.03
Rate for Payer: Multiplan Commercial	$218.55
Rate for Payer: Multiplan Commercial	$113.22

ISOTRETINOIN 10 MG CAPSULE [10359]

Facility

$6.02

Service Code	NDC 0378-6611-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.31
Rate for Payer: Multiplan Commercial	$4.51

ISOTRETINOIN 10 MG CAPSULE [10359]

Facility

$6.02

Service Code	NDC 0378-6611-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.61
Rate for Payer: Aetna of CA Government/Medicare	$3.61
Rate for Payer: Cash Price	$3.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.31
Rate for Payer: Multiplan Commercial	$4.51

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$7.14

Service Code	NDC 0378-6612-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.71
Rate for Payer: Cash Price	$3.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.71
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Commercial	$5.36

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$7.58

Service Code	NDC 0555-1055-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$6.06
Rate for Payer: Cash Price	$4.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.06
Rate for Payer: Health Smart Auto/Commercial	$4.55
Rate for Payer: LLUH Dept of Risk Management WC	$4.17
Rate for Payer: Multiplan Commercial	$5.68

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$7.14

Service Code	NDC 0378-6612-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.28
Rate for Payer: Aetna of CA Government/Medicare	$4.28
Rate for Payer: Cash Price	$3.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.71
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Commercial	$5.36

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$7.58

Service Code	NDC 0555-1055-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$6.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.55
Rate for Payer: Aetna of CA Government/Medicare	$4.55
Rate for Payer: Cash Price	$4.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.06
Rate for Payer: Health Smart Auto/Commercial	$4.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.55
Rate for Payer: LLUH Dept of Risk Management WC	$4.17
Rate for Payer: Multiplan Commercial	$5.68

ISOTRETINOIN 40 MG CAPSULE [10361]

Facility

$8.30

Service Code	NDC 0378-6614-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$6.64
Rate for Payer: Cash Price	$4.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.64
Rate for Payer: Health Smart Auto/Commercial	$4.98
Rate for Payer: LLUH Dept of Risk Management WC	$4.57
Rate for Payer: Multiplan Commercial	$6.22

ISOTRETINOIN 40 MG CAPSULE [10361]

Facility

$8.30

Service Code	NDC 0378-6614-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$6.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.98
Rate for Payer: Aetna of CA Government/Medicare	$4.98
Rate for Payer: Cash Price	$4.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.64
Rate for Payer: Health Smart Auto/Commercial	$4.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.98
Rate for Payer: LLUH Dept of Risk Management WC	$4.57
Rate for Payer: Multiplan Commercial	$6.22

ISRADIPINE 2.5 MG CAPSULE [10362]

Facility

$1.73

Service Code	NDC 16252-539-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Cash Price	$0.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Commercial	$1.30

ISRADIPINE 2.5 MG CAPSULE [10362]

Facility

$1.73

Service Code	NDC 16252-539-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Commercial	$1.30

ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]

Facility

$0.40

Service Code	NDC 9994-0802-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]

Facility

$0.40

Service Code	NDC 9994-0802-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$34.45

Service Code	NDC 50458-290-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.67
Rate for Payer: Aetna of CA Government/Medicare	$20.67
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.56
Rate for Payer: Health Smart Auto/Commercial	$20.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.67
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 49884-239-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 67877-454-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$34.45

Service Code	NDC 50458-290-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.56
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.56
Rate for Payer: Health Smart Auto/Commercial	$20.67
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 65162-630-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 67877-454-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 65162-630-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 49884-239-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]

Facility

$2.35

Service Code	NDC 65162-087-74
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.41
Rate for Payer: Aetna of CA Government/Medicare	$1.41
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.88
Rate for Payer: Health Smart Auto/Commercial	$1.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.76

ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]

Facility

$2.35

Service Code	NDC 65162-087-74
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.88
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.88
Rate for Payer: Health Smart Auto/Commercial	$1.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.76

Know your out-of-pocket cost for care.

All Charges