Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]

Facility

$39.60

Service Code	CPT J0457
Hospital Charge Code	1721161
Hospital Revenue Code	636
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.40
Rate for Payer: Aetna of CA Government/Medicare	$21.40
Rate for Payer: Aetna of CA Government/Medicare	$23.76
Rate for Payer: Aetna of CA Government/Medicare	$25.98
Rate for Payer: Cash Price	$16.05
Rate for Payer: Cash Price	$19.49
Rate for Payer: Cash Price	$17.82
Rate for Payer: Health Smart Auto/Commercial	$21.40
Rate for Payer: Health Smart Auto/Commercial	$25.98
Rate for Payer: Health Smart Auto/Commercial	$23.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.76
Rate for Payer: LLUH Dept of Risk Management WC	$23.82
Rate for Payer: LLUH Dept of Risk Management WC	$21.78
Rate for Payer: LLUH Dept of Risk Management WC	$19.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.75

AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]

Facility

$43.30

Service Code	CPT J0457
Hospital Charge Code	1721161
Hospital Revenue Code	636
Min. Negotiated Rate	$23.82
Max. Negotiated Rate	$34.64
Rate for Payer: Cash Price	$19.49
Rate for Payer: Cash Price	$17.82
Rate for Payer: Cash Price	$16.05
Rate for Payer: Cigna of CA HMO/PPO	$28.54
Rate for Payer: Cigna of CA HMO/PPO	$31.68
Rate for Payer: Cigna of CA HMO/PPO	$34.64
Rate for Payer: Health Smart Auto/Commercial	$25.98
Rate for Payer: Health Smart Auto/Commercial	$23.76
Rate for Payer: Health Smart Auto/Commercial	$21.40
Rate for Payer: LLUH Dept of Risk Management WC	$19.62
Rate for Payer: LLUH Dept of Risk Management WC	$23.82
Rate for Payer: LLUH Dept of Risk Management WC	$21.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.48

AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]

Facility

$78.00

Service Code	CPT J0457
Hospital Charge Code	1753314
Hospital Revenue Code	636
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$58.50
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: Health Smart Auto/Commercial	$52.78
Rate for Payer: Health Smart Auto/Commercial	$42.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$46.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.78
Rate for Payer: Aetna of CA Government/Medicare	$46.80
Rate for Payer: Aetna of CA Government/Medicare	$42.80
Rate for Payer: Aetna of CA Government/Medicare	$52.78
Rate for Payer: Cash Price	$39.59
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$32.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$46.80
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: LLUH Dept of Risk Management WC	$39.24
Rate for Payer: LLUH Dept of Risk Management WC	$48.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$58.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.98

AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]

Facility

$71.34

Service Code	CPT J0457
Hospital Charge Code	1753314
Hospital Revenue Code	636
Min. Negotiated Rate	$39.24
Max. Negotiated Rate	$57.07
Rate for Payer: Cash Price	$32.10
Rate for Payer: Cash Price	$39.59
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna of CA HMO/PPO	$62.40
Rate for Payer: Cigna of CA HMO/PPO	$70.38
Rate for Payer: Cigna of CA HMO/PPO	$57.07
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: Health Smart Auto/Commercial	$42.80
Rate for Payer: Health Smart Auto/Commercial	$52.78
Rate for Payer: LLUH Dept of Risk Management WC	$48.38
Rate for Payer: LLUH Dept of Risk Management WC	$39.24
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$58.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.50

AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]

Facility

$148.49

Service Code	NDC 61958-0901-1
Hospital Charge Code	NDG100393
Hospital Revenue Code	259
Min. Negotiated Rate	$81.67
Max. Negotiated Rate	$111.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$89.09
Rate for Payer: Aetna of CA Government/Medicare	$89.09
Rate for Payer: Cash Price	$66.82
Rate for Payer: Health Smart Auto/Commercial	$89.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$89.09
Rate for Payer: LLUH Dept of Risk Management WC	$81.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$111.37

AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]

Facility

$148.49

Service Code	NDC 61958-0901-1
Hospital Charge Code	NDG100393
Hospital Revenue Code	259
Min. Negotiated Rate	$81.67
Max. Negotiated Rate	$118.79
Rate for Payer: Cash Price	$66.82
Rate for Payer: Cigna of CA HMO/PPO	$118.79
Rate for Payer: Health Smart Auto/Commercial	$89.09
Rate for Payer: LLUH Dept of Risk Management WC	$81.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$111.37

BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]

Facility

$37.06

Service Code	NDC 0574-4022-35
Hospital Charge Code	1740071
Hospital Revenue Code	259
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$27.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.24
Rate for Payer: Aetna of CA Government/Medicare	$22.24
Rate for Payer: Cash Price	$16.68
Rate for Payer: Health Smart Auto/Commercial	$22.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.24
Rate for Payer: LLUH Dept of Risk Management WC	$20.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.80

BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]

Facility

$37.06

Service Code	NDC 0574-4022-35
Hospital Charge Code	1740071
Hospital Revenue Code	259
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$29.65
Rate for Payer: Cash Price	$16.68
Rate for Payer: Cigna of CA HMO/PPO	$29.65
Rate for Payer: Health Smart Auto/Commercial	$22.24
Rate for Payer: LLUH Dept of Risk Management WC	$20.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.80

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.09

Service Code	NDC 68001-477-47
Hospital Charge Code	1743006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.09

Service Code	NDC 0713-0280-31
Hospital Charge Code	1743006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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: 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	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.15

Service Code	NDC 45802-060-01
Hospital Charge Code	1719221
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.08

Service Code	NDC 0536-1256-28
Hospital Charge Code	NDG850B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.06

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.15

Service Code	NDC 45802-060-01
Hospital Charge Code	1719221
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.11

Service Code	NDC 45802-060-03
Hospital Charge Code	1743006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.11

Service Code	NDC 45802-060-03
Hospital Charge Code	1743006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.08

Service Code	NDC 0536-1256-28
Hospital Charge Code	NDG850B
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: 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 Beech St/Commercial/PHCS	$0.06

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.09

Service Code	NDC 68001-477-47
Hospital Charge Code	1743006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Cash Price	$0.04
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]

Facility

$0.09

Service Code	NDC 0713-0280-31
Hospital Charge Code	1743006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 45802-060-00
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 68001-477-48
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 68001-477-45
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 68001-477-48
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 45802-060-70
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 45802-060-70
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]

Facility

$0.16

Service Code	NDC 45802-060-00
Hospital Charge Code	1743769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

Know your out-of-pocket cost for care.

All Charges