Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MEMANTINE 5 MG TABLET [37170]

Facility

$0.58

Service Code	NDC 60687-173-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

MEMANTINE 5 MG TABLET [37170]

Facility

$0.24

Service Code	NDC 47335-321-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

MEMANTINE 5 MG TABLET [37170]

Facility

$0.58

Service Code	NDC 60687-173-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

MEMANTINE 5 MG TABLET [37170]

Facility

$0.19

Service Code	NDC 72578-003-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
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	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
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

MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]

Facility

$567.30

Service Code	HCPCS 90620
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$312.01
Max. Negotiated Rate	$453.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$340.38
Rate for Payer: Aetna of CA Government/Medicare	$340.38
Rate for Payer: Cash Price	$312.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$453.84
Rate for Payer: Health Smart Auto/Commercial	$340.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$340.38
Rate for Payer: LLUH Dept of Risk Management WC	$312.01
Rate for Payer: Multiplan Commercial	$425.48

MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]

Facility

$567.30

Service Code	HCPCS 90620
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$312.01
Max. Negotiated Rate	$453.84
Rate for Payer: Cash Price	$312.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$453.84
Rate for Payer: Health Smart Auto/Commercial	$340.38
Rate for Payer: LLUH Dept of Risk Management WC	$312.01
Rate for Payer: Multiplan Commercial	$425.48

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$398.39

Service Code	NDC 58160-827-03
Min. Negotiated Rate	$219.11
Max. Negotiated Rate	$318.71
Rate for Payer: Cash Price	$219.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$318.71
Rate for Payer: Health Smart Auto/Commercial	$239.03
Rate for Payer: LLUH Dept of Risk Management WC	$219.11
Rate for Payer: Multiplan Commercial	$298.79

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$398.39

Service Code	NDC 58160-827-03
Min. Negotiated Rate	$219.11
Max. Negotiated Rate	$318.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$239.03
Rate for Payer: Aetna of CA Government/Medicare	$239.03
Rate for Payer: Cash Price	$219.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$318.71
Rate for Payer: Health Smart Auto/Commercial	$239.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$239.03
Rate for Payer: LLUH Dept of Risk Management WC	$219.11
Rate for Payer: Multiplan Commercial	$298.79

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$398.39

Service Code	NDC 58160-827-30
Min. Negotiated Rate	$219.11
Max. Negotiated Rate	$318.71
Rate for Payer: Cash Price	$219.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$318.71
Rate for Payer: Health Smart Auto/Commercial	$239.03
Rate for Payer: LLUH Dept of Risk Management WC	$219.11
Rate for Payer: Multiplan Commercial	$298.79

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$398.39

Service Code	NDC 58160-827-30
Min. Negotiated Rate	$219.11
Max. Negotiated Rate	$318.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$239.03
Rate for Payer: Aetna of CA Government/Medicare	$239.03
Rate for Payer: Cash Price	$219.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$318.71
Rate for Payer: Health Smart Auto/Commercial	$239.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$239.03
Rate for Payer: LLUH Dept of Risk Management WC	$219.11
Rate for Payer: Multiplan Commercial	$298.79

MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]

Facility

$199.20

Service Code	HCPCS 90734
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$109.56
Max. Negotiated Rate	$159.36
Rate for Payer: Cash Price	$109.56
Rate for Payer: Cash Price	$167.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$243.84
Rate for Payer: Health Smart Auto/Commercial	$119.52
Rate for Payer: Health Smart Auto/Commercial	$182.88
Rate for Payer: LLUH Dept of Risk Management WC	$167.64
Rate for Payer: LLUH Dept of Risk Management WC	$109.56
Rate for Payer: Multiplan Commercial	$149.40
Rate for Payer: Multiplan Commercial	$228.60

MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]

Facility

$199.20

Service Code	HCPCS 90734
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$109.56
Max. Negotiated Rate	$159.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$182.88
Rate for Payer: Aetna of CA Government/Medicare	$119.52
Rate for Payer: Aetna of CA Government/Medicare	$182.88
Rate for Payer: Cash Price	$109.56
Rate for Payer: Cash Price	$167.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$243.84
Rate for Payer: Health Smart Auto/Commercial	$119.52
Rate for Payer: Health Smart Auto/Commercial	$182.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$182.88
Rate for Payer: LLUH Dept of Risk Management WC	$167.64
Rate for Payer: LLUH Dept of Risk Management WC	$109.56
Rate for Payer: Multiplan Commercial	$149.40
Rate for Payer: Multiplan Commercial	$228.60

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]

Facility

$0.04

Service Code	NDC 10135-701-04
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

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]

Facility

$0.04

Service Code	NDC 10135-701-04
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

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]

Facility

$0.14

Service Code	NDC 0799-0001-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]

Facility

$0.14

Service Code	NDC 0799-0001-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]

Facility

$5.50

Service Code	HCPCS J2175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$4.40
Rate for Payer: Cash Price	$3.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.40
Rate for Payer: Health Smart Auto/Commercial	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Commercial	$4.12

MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]

Facility

$5.50

Service Code	HCPCS J2175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$4.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.30
Rate for Payer: Aetna of CA Government/Medicare	$3.30
Rate for Payer: Cash Price	$3.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.40
Rate for Payer: Health Smart Auto/Commercial	$3.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Commercial	$4.12

MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION [117787]

Facility

$3.04

Service Code	HCPCS J2175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.82
Rate for Payer: Aetna of CA Government/Medicare	$1.82
Rate for Payer: Cash Price	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.43
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$2.28

MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION [117787]

Facility

$3.04

Service Code	HCPCS J2175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Cash Price	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.43
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$2.28

MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION [4904]

Facility

$3.17

Service Code	HCPCS J2175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.54
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.54
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.38

MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION [4904]

Facility

$3.17

Service Code	HCPCS J2175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.54
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.38

MEPIVACAINE 30 MG/ML (3 %) INJECTION DENTAL CARTRIDGE [214023]

Facility

$0.38

Service Code	NDC 50227-1080-5
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

MEPIVACAINE 30 MG/ML (3 %) INJECTION DENTAL CARTRIDGE [214023]

Facility

$0.38

Service Code	NDC 50227-1080-5
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

MEPIVACAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION [10529]

Facility

$0.60

Service Code	HCPCS J0670
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

Know your out-of-pocket cost for care.

All Charges