Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 750 MG TABLET [26818]

Facility

$0.12

Service Code	NDC 72205-096-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

LEVETIRACETAM 750 MG TABLET [26818]

Facility

$0.34

Service Code	NDC 0904-7125-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LEVETIRACETAM 750 MG TABLET [26818]

Facility

$0.47

Service Code	NDC 68084-882-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]

Facility

$11.01

Service Code	NDC 50474-598-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$8.81
Rate for Payer: Cash Price	$6.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.81
Rate for Payer: Health Smart Auto/Commercial	$6.61
Rate for Payer: LLUH Dept of Risk Management WC	$6.06
Rate for Payer: Multiplan Commercial	$8.26

LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]

Facility

$11.01

Service Code	NDC 50474-598-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$8.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.61
Rate for Payer: Aetna of CA Government/Medicare	$6.61
Rate for Payer: Cash Price	$6.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.81
Rate for Payer: Health Smart Auto/Commercial	$6.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.61
Rate for Payer: LLUH Dept of Risk Management WC	$6.06
Rate for Payer: Multiplan Commercial	$8.26

LEVOBUNOLOL 0.5 % EYE DROPS [10394]

Facility

$4.30

Service Code	NDC 24208-505-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$3.44
Rate for Payer: Cash Price	$2.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.44
Rate for Payer: Health Smart Auto/Commercial	$2.58
Rate for Payer: LLUH Dept of Risk Management WC	$2.37
Rate for Payer: Multiplan Commercial	$3.23

LEVOBUNOLOL 0.5 % EYE DROPS [10394]

Facility

$4.30

Service Code	NDC 24208-505-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.58
Rate for Payer: Aetna of CA Government/Medicare	$2.58
Rate for Payer: Cash Price	$2.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.44
Rate for Payer: Health Smart Auto/Commercial	$2.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.58
Rate for Payer: LLUH Dept of Risk Management WC	$2.37
Rate for Payer: Multiplan Commercial	$3.23

LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]

Facility

$0.35

Service Code	NDC 70954-140-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]

Facility

$0.35

Service Code	NDC 70954-140-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]

Facility

$9.33

Service Code	HCPCS J1955
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$7.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.60
Rate for Payer: Aetna of CA Government/Medicare	$5.60
Rate for Payer: Cash Price	$5.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.46
Rate for Payer: Health Smart Auto/Commercial	$5.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.60
Rate for Payer: LLUH Dept of Risk Management WC	$5.13
Rate for Payer: Multiplan Commercial	$7.00

LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]

Facility

$9.33

Service Code	HCPCS J1955
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$7.46
Rate for Payer: Cash Price	$5.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.46
Rate for Payer: Health Smart Auto/Commercial	$5.60
Rate for Payer: LLUH Dept of Risk Management WC	$5.13
Rate for Payer: Multiplan Commercial	$7.00

LEVOCARNITINE 330 MG TABLET [20952]

Facility

$1.05

Service Code	NDC 70954-492-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.84
Rate for Payer: Cash Price	$0.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.84
Rate for Payer: Health Smart Auto/Commercial	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Commercial	$0.79

LEVOCARNITINE 330 MG TABLET [20952]

Facility

$1.50

Service Code	NDC 54482-144-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

LEVOCARNITINE 330 MG TABLET [20952]

Facility

$1.50

Service Code	NDC 54482-144-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

LEVOCARNITINE 330 MG TABLET [20952]

Facility

$1.05

Service Code	NDC 70954-492-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.63
Rate for Payer: Aetna of CA Government/Medicare	$0.63
Rate for Payer: Cash Price	$0.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.84
Rate for Payer: Health Smart Auto/Commercial	$0.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Commercial	$0.79

LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION [41623]

Facility

$0.21

Service Code	NDC 52817-830-04
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	$0.11
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

LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION [41623]

Facility

$0.21

Service Code	NDC 52817-830-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.11
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

LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]

Facility

$3.05

Service Code	NDC 0527-1948-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.83
Rate for Payer: Aetna of CA Government/Medicare	$1.83
Rate for Payer: Cash Price	$1.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.44
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Commercial	$2.29

LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]

Facility

$3.05

Service Code	NDC 0527-1948-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.44
Rate for Payer: Cash Price	$1.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.44
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Commercial	$2.29

LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]

Facility

$3.08

Service Code	NDC 0527-1948-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Cash Price	$1.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$2.31

LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]

Facility

$3.08

Service Code	NDC 0527-1948-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.85
Rate for Payer: Aetna of CA Government/Medicare	$1.85
Rate for Payer: Cash Price	$1.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$2.31

LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]

Facility

$0.10

Service Code	HCPCS J1956
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$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: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.06
Rate for Payer: Multiplan Commercial	$0.08

LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]

Facility

$0.08

Service Code	HCPCS J1956
Hospital Charge Code	901700025
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08
Rate for Payer: Multiplan Commercial	$0.06

LEVOFLOXACIN 250 MG TABLET [18918]

Facility

$0.38

Service Code	NDC 65862-536-50
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

LEVOFLOXACIN 250 MG TABLET [18918]

Facility

$0.26

Service Code	NDC 0904-6351-61
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	$0.15
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

Know your out-of-pocket cost for care.

All Charges