Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ATORVASTATIN 40 MG TABLET [19177]

Facility

$0.54

Service Code	NDC 68084-099-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ATORVASTATIN 40 MG TABLET [19177]

Facility

$0.38

Service Code	NDC 0904-6292-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
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

ATORVASTATIN 40 MG TABLET [19177]

Facility

$0.18

Service Code	NDC 0378-3952-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
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	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

ATORVASTATIN 40 MG TABLET [19177]

Facility

$0.38

Service Code	NDC 0904-6292-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
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	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
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

ATORVASTATIN 40 MG TABLET [19177]

Facility

$0.54

Service Code	NDC 68084-099-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.29

Service Code	NDC 60505-2671-9
Hospital Charge Code	901700029
Hospital Revenue Code	259
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 Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.18

Service Code	NDC 0378-3953-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
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	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.21

Service Code	NDC 63304-830-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.16

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.52

Service Code	NDC 0904-6293-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.18

Service Code	NDC 0378-3953-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
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	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.21

Service Code	NDC 63304-830-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.16

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.29

Service Code	NDC 60505-2671-9
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.52

Service Code	NDC 0904-6293-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.36

Service Code	NDC 59762-0158-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.36

Service Code	NDC 59762-0158-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.81

Service Code	NDC 68084-590-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

ATORVASTATIN 80 MG TABLET [28645]

Facility

$0.81

Service Code	NDC 68084-590-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

ATOVAQUONE 250 MG-PROGUANIL 100 MG TABLET [23814]

Facility

$7.00

Service Code	NDC 68001-245-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$3.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Commercial	$5.25

ATOVAQUONE 250 MG-PROGUANIL 100 MG TABLET [23814]

Facility

$8.24

Service Code	NDC 0173-0675-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.53
Max. Negotiated Rate	$6.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.94
Rate for Payer: Aetna of CA Government/Medicare	$4.94
Rate for Payer: Cash Price	$4.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.59
Rate for Payer: Health Smart Auto/Commercial	$4.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.94
Rate for Payer: LLUH Dept of Risk Management WC	$4.53
Rate for Payer: Multiplan Commercial	$6.18

ATOVAQUONE 250 MG-PROGUANIL 100 MG TABLET [23814]

Facility

$7.00

Service Code	NDC 68001-245-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.20
Rate for Payer: Aetna of CA Government/Medicare	$4.20
Rate for Payer: Cash Price	$3.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Commercial	$5.25

ATOVAQUONE 250 MG-PROGUANIL 100 MG TABLET [23814]

Facility

$8.24

Service Code	NDC 0173-0675-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.53
Max. Negotiated Rate	$6.59
Rate for Payer: Cash Price	$4.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.59
Rate for Payer: Health Smart Auto/Commercial	$4.94
Rate for Payer: LLUH Dept of Risk Management WC	$4.53
Rate for Payer: Multiplan Commercial	$6.18

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$2.29

Service Code	NDC 68462-421-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.83
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.83
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.72

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$2.29

Service Code	NDC 70748-299-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.83
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.83
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.72

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$2.29

Service Code	NDC 68462-421-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.37
Rate for Payer: Aetna of CA Government/Medicare	$1.37
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.83
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.72

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$2.29

Service Code	NDC 0121-0956-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.37
Rate for Payer: Aetna of CA Government/Medicare	$1.37
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.83
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.72

Know your out-of-pocket cost for care.

All Charges