Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ATROPINE 1 % EYE DROPS < 2 ML (PROCEDURAL) [408736]

Facility

$13.03

Service Code	NDC 0065-0817-01
Hospital Charge Code	1740156
Hospital Revenue Code	259
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$9.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.82
Rate for Payer: Aetna of CA Government/Medicare	$7.82
Rate for Payer: Cash Price	$5.86
Rate for Payer: Health Smart Auto/Commercial	$7.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.82
Rate for Payer: LLUH Dept of Risk Management WC	$7.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.77

ATROPINE 1 % EYE DROPS [736]

Facility

$21.54

Service Code	NDC 60219-1748-2
Hospital Charge Code	1740347
Hospital Revenue Code	250
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$17.23
Rate for Payer: Cash Price	$9.69
Rate for Payer: Cigna of CA HMO/PPO	$17.23
Rate for Payer: Health Smart Auto/Commercial	$12.92
Rate for Payer: LLUH Dept of Risk Management WC	$11.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.16

ATROPINE 1 % EYE DROPS [736]

Facility

$21.00

Service Code	NDC 0065-0817-02
Hospital Charge Code	1740347
Hospital Revenue Code	250
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$16.80
Rate for Payer: Cash Price	$9.45
Rate for Payer: Cigna of CA HMO/PPO	$16.80
Rate for Payer: Health Smart Auto/Commercial	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.75

ATROPINE 1 % EYE DROPS [736]

Facility

$21.00

Service Code	NDC 0065-0817-02
Hospital Charge Code	1740347
Hospital Revenue Code	250
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$15.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.60
Rate for Payer: Aetna of CA Government/Medicare	$12.60
Rate for Payer: Cash Price	$9.45
Rate for Payer: Health Smart Auto/Commercial	$12.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.75

ATROPINE 1 % EYE DROPS [736]

Facility

$21.54

Service Code	NDC 60219-1748-2
Hospital Charge Code	1740347
Hospital Revenue Code	250
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$16.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.92
Rate for Payer: Aetna of CA Government/Medicare	$12.92
Rate for Payer: Cash Price	$9.69
Rate for Payer: Health Smart Auto/Commercial	$12.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.92
Rate for Payer: LLUH Dept of Risk Management WC	$11.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.16

ATROPINE 1 % EYE OINTMENT [735]

Facility

$6.00

Service Code	NDC 24208-825-55
Hospital Charge Code	1740063
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

ATROPINE 1 % EYE OINTMENT [735]

Facility

$6.00

Service Code	NDC 24208-825-55
Hospital Charge Code	1740063
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

ATROPINE 1 MG/ML INJECTION SOLUTION [734]

Facility

$15.07

Service Code	CPT J0461
Hospital Charge Code	1721185
Hospital Revenue Code	636
Min. Negotiated Rate	$8.29
Max. Negotiated Rate	$12.06
Rate for Payer: Cash Price	$6.78
Rate for Payer: Cigna of CA HMO/PPO	$12.06
Rate for Payer: Health Smart Auto/Commercial	$9.04
Rate for Payer: LLUH Dept of Risk Management WC	$8.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.30

ATROPINE 1 MG/ML INJECTION SOLUTION [734]

Facility

$15.07

Service Code	CPT J0461
Hospital Charge Code	1721185
Hospital Revenue Code	636
Min. Negotiated Rate	$8.29
Max. Negotiated Rate	$11.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.04
Rate for Payer: Aetna of CA Government/Medicare	$9.04
Rate for Payer: Cash Price	$6.78
Rate for Payer: Health Smart Auto/Commercial	$9.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.04
Rate for Payer: LLUH Dept of Risk Management WC	$8.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.30

ATROPINE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080421]

Facility

$2.10

Service Code	NDC 9994-0804-21
Hospital Charge Code	1721189
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.26
Rate for Payer: Aetna of CA Government/Medicare	$1.26
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.58

ATROPINE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080421]

Facility

$2.10

Service Code	NDC 9994-0804-21
Hospital Charge Code	1721189
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.68
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cigna of CA HMO/PPO	$1.68
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.58

AVAPRITINIB 100 MG TABLET [226931]

Facility

$1,408.52

Service Code	NDC 72064-110-30
Hospital Charge Code	ERX226931
Hospital Revenue Code	259
Min. Negotiated Rate	$774.69
Max. Negotiated Rate	$1,126.82
Rate for Payer: Cash Price	$633.83
Rate for Payer: Cigna of CA HMO/PPO	$1,126.82
Rate for Payer: Health Smart Auto/Commercial	$845.11
Rate for Payer: LLUH Dept of Risk Management WC	$774.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,056.39

AVAPRITINIB 100 MG TABLET [226931]

Facility

$1,408.52

Service Code	NDC 72064-110-30
Hospital Charge Code	ERX226931
Hospital Revenue Code	259
Min. Negotiated Rate	$774.69
Max. Negotiated Rate	$1,056.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$845.11
Rate for Payer: Aetna of CA Government/Medicare	$845.11
Rate for Payer: Cash Price	$633.83
Rate for Payer: Health Smart Auto/Commercial	$845.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$845.11
Rate for Payer: LLUH Dept of Risk Management WC	$774.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,056.39

AVAPRITINIB 200 MG TABLET [226932]

Facility

$1,408.52

Service Code	NDC 72064-120-30
Hospital Charge Code	ERX226932
Hospital Revenue Code	259
Min. Negotiated Rate	$774.69
Max. Negotiated Rate	$1,056.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$845.11
Rate for Payer: Aetna of CA Government/Medicare	$845.11
Rate for Payer: Cash Price	$633.83
Rate for Payer: Health Smart Auto/Commercial	$845.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$845.11
Rate for Payer: LLUH Dept of Risk Management WC	$774.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,056.39

AVAPRITINIB 200 MG TABLET [226932]

Facility

$1,408.52

Service Code	NDC 72064-120-30
Hospital Charge Code	ERX226932
Hospital Revenue Code	259
Min. Negotiated Rate	$774.69
Max. Negotiated Rate	$1,126.82
Rate for Payer: Cash Price	$633.83
Rate for Payer: Cigna of CA HMO/PPO	$1,126.82
Rate for Payer: Health Smart Auto/Commercial	$845.11
Rate for Payer: LLUH Dept of Risk Management WC	$774.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,056.39

AVAPRITINIB 300 MG TABLET [226933]

Facility

$1,408.52

Service Code	NDC 72064-130-30
Hospital Charge Code	ERX226933
Hospital Revenue Code	259
Min. Negotiated Rate	$774.69
Max. Negotiated Rate	$1,126.82
Rate for Payer: Cash Price	$633.83
Rate for Payer: Cigna of CA HMO/PPO	$1,126.82
Rate for Payer: Health Smart Auto/Commercial	$845.11
Rate for Payer: LLUH Dept of Risk Management WC	$774.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,056.39

AVAPRITINIB 300 MG TABLET [226933]

Facility

$1,408.52

Service Code	NDC 72064-130-30
Hospital Charge Code	ERX226933
Hospital Revenue Code	259
Min. Negotiated Rate	$774.69
Max. Negotiated Rate	$1,056.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$845.11
Rate for Payer: Aetna of CA Government/Medicare	$845.11
Rate for Payer: Cash Price	$633.83
Rate for Payer: Health Smart Auto/Commercial	$845.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$845.11
Rate for Payer: LLUH Dept of Risk Management WC	$774.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,056.39

AZACITIDINE 100 MG (10 MG/ML) INTRAVENOUS INJECTION [40878420]

Facility

$702.29

Service Code	CPT J9025
Hospital Charge Code	ERX40878420
Hospital Revenue Code	636
Min. Negotiated Rate	$386.26
Max. Negotiated Rate	$561.83
Rate for Payer: Cash Price	$316.03
Rate for Payer: Cigna of CA HMO/PPO	$561.83
Rate for Payer: Health Smart Auto/Commercial	$421.37
Rate for Payer: LLUH Dept of Risk Management WC	$386.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$526.72

AZACITIDINE 100 MG (10 MG/ML) INTRAVENOUS INJECTION [40878420]

Facility

$702.29

Service Code	CPT J9025
Hospital Charge Code	ERX40878420
Hospital Revenue Code	636
Min. Negotiated Rate	$386.26
Max. Negotiated Rate	$526.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$421.37
Rate for Payer: Aetna of CA Government/Medicare	$421.37
Rate for Payer: Cash Price	$316.03
Rate for Payer: Health Smart Auto/Commercial	$421.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$421.37
Rate for Payer: LLUH Dept of Risk Management WC	$386.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$526.72

AZACITIDINE 100 MG (25 MG/ML) SUBCUTANEOUS INJECTION [408000276]

Facility

$120.00

Service Code	CPT J9025
Hospital Revenue Code	636
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$129.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.80
Rate for Payer: Aetna of CA Government/Medicare	$64.80
Rate for Payer: Aetna of CA Government/Medicare	$126.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$129.60
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Smart Auto/Commercial	$129.60
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$129.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$118.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$162.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$157.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$81.00

AZACITIDINE 100 MG (25 MG/ML) SUBCUTANEOUS INJECTION [408000276]

Facility

$210.00

Service Code	CPT J9025
Hospital Revenue Code	636
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$168.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna of CA HMO/PPO	$96.00
Rate for Payer: Cigna of CA HMO/PPO	$168.00
Rate for Payer: Cigna of CA HMO/PPO	$172.80
Rate for Payer: Cigna of CA HMO/PPO	$86.40
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Health Smart Auto/Commercial	$129.60
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$118.80
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$162.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$81.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$157.50

AZACITIDINE 100 MG INJECTION [78420]

Facility

$120.00

Service Code	CPT J9025
Hospital Charge Code	1755716
Hospital Revenue Code	636
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$96.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna of CA HMO/PPO	$168.00
Rate for Payer: Cigna of CA HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$157.50

AZACITIDINE 100 MG INJECTION [78420]

Facility

$210.00

Service Code	CPT J9025
Hospital Charge Code	1755716
Hospital Revenue Code	636
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$126.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.00
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$157.50

AZATHIOPRINE 25 MG 1/2 TAB [4081407]

Facility

$0.81

Service Code	CPT J7500
Hospital Charge Code	NDC4081407
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.61

AZATHIOPRINE 25 MG 1/2 TAB [4081407]

Facility

$0.81

Service Code	CPT J7500
Hospital Charge Code	ERX4081407
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

Know your out-of-pocket cost for care.

All Charges