Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LACTOBACILLUS RHAMNOSUS GG 5 BILLION CELL ORAL POWDER PACKET [205489]

Facility

$0.72

Service Code	NDC 4910040008
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG CHEWABLE TABLET [208814]

Facility

$0.84

Service Code	NDC 4910040022
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG CHEWABLE TABLET [208814]

Facility

$0.84

Service Code	NDC 4910040022
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE [196964]

Facility

$0.60

Service Code	NDC 4910040009
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE [196964]

Facility

$0.60

Service Code	NDC 4910040009
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (BULK) [38245]

Facility

$0.02

Service Code	NDC 45963-439-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (BULK) [38245]

Facility

$0.02

Service Code	NDC 45963-439-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (BULK) [38245]

Facility

$0.04

Service Code	NDC 0116-4005-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (BULK) [38245]

Facility

$0.04

Service Code	NDC 0116-4005-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

LACTULOSE 10 GRAM ORAL PACKET [18334]

Facility

$10.34

Service Code	NDC 0121-0965-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$8.27
Rate for Payer: Cash Price	$5.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.27
Rate for Payer: Health Smart Auto/Commercial	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Commercial	$7.75

LACTULOSE 10 GRAM ORAL PACKET [18334]

Facility

$10.34

Service Code	NDC 0121-0965-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$8.27
Rate for Payer: Cash Price	$5.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.27
Rate for Payer: Health Smart Auto/Commercial	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Commercial	$7.75

LACTULOSE 10 GRAM ORAL PACKET [18334]

Facility

$10.34

Service Code	NDC 0121-0965-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$8.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.20
Rate for Payer: Aetna of CA Government/Medicare	$6.20
Rate for Payer: Cash Price	$5.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.27
Rate for Payer: Health Smart Auto/Commercial	$6.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Commercial	$7.75

LACTULOSE 10 GRAM ORAL PACKET [18334]

Facility

$10.34

Service Code	NDC 0121-0965-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$8.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.20
Rate for Payer: Aetna of CA Government/Medicare	$6.20
Rate for Payer: Cash Price	$5.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.27
Rate for Payer: Health Smart Auto/Commercial	$6.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Commercial	$7.75

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.08

Service Code	NDC 0121-1154-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.07

Service Code	NDC 0121-1154-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.05

Service Code	NDC 99991889280
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.05

Service Code	NDC 99991889280
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.08

Service Code	NDC 0121-1154-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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	$0.04
Rate for Payer: Multiplan Commercial	$0.06

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.07

Service Code	NDC 0116-4005-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.07

Service Code	NDC 0116-4005-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.07

Service Code	NDC 0116-4005-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.07

Service Code	NDC 0116-4005-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION [188928]

Facility

$0.07

Service Code	NDC 0121-1154-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

LACTULOSE 20 GRAM ORAL PACKET [24586]

Facility

$12.18

Service Code	NDC 66220-729-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$9.74
Rate for Payer: Cash Price	$6.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.74
Rate for Payer: Health Smart Auto/Commercial	$7.31
Rate for Payer: LLUH Dept of Risk Management WC	$6.70
Rate for Payer: Multiplan Commercial	$9.13

LACTULOSE 20 GRAM ORAL PACKET [24586]

Facility

$12.18

Service Code	NDC 66220-729-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$9.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.31
Rate for Payer: Aetna of CA Government/Medicare	$7.31
Rate for Payer: Cash Price	$6.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.74
Rate for Payer: Health Smart Auto/Commercial	$7.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.31
Rate for Payer: LLUH Dept of Risk Management WC	$6.70
Rate for Payer: Multiplan Commercial	$9.13

Know your out-of-pocket cost for care.

All Charges