Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]

Facility

$0.82

Service Code	NDC 43199-011-01
Hospital Charge Code	1711556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.66
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	$0.62

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]

Facility

$0.54

Service Code	NDC 42192-339-01
Hospital Charge Code	1711556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]

Facility

$0.82

Service Code	NDC 43199-011-01
Hospital Charge Code	1711556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]

Facility

$0.54

Service Code	NDC 42192-339-01
Hospital Charge Code	1711556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]

Facility

$80.30

Service Code	CPT J1980
Hospital Charge Code	1720837
Hospital Revenue Code	636
Min. Negotiated Rate	$44.16
Max. Negotiated Rate	$60.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.18
Rate for Payer: Aetna of CA Government/Medicare	$48.18
Rate for Payer: Cash Price	$36.14
Rate for Payer: Health Smart Auto/Commercial	$48.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.18
Rate for Payer: LLUH Dept of Risk Management WC	$44.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.22

HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]

Facility

$80.30

Service Code	CPT J1980
Hospital Charge Code	1720837
Hospital Revenue Code	636
Min. Negotiated Rate	$44.16
Max. Negotiated Rate	$64.24
Rate for Payer: Cash Price	$36.14
Rate for Payer: Cigna of CA HMO/PPO	$64.24
Rate for Payer: Health Smart Auto/Commercial	$48.18
Rate for Payer: LLUH Dept of Risk Management WC	$44.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.22

HYPROMELLOSE 2.5 % EYE DROPS [38092]

Facility

$1.55

Service Code	NDC 17478-064-12
Hospital Charge Code	1740135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.93
Rate for Payer: Aetna of CA Government/Medicare	$0.93
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.93
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.16

HYPROMELLOSE 2.5 % EYE DROPS [38092]

Facility

$1.55

Service Code	NDC 17478-064-12
Hospital Charge Code	1740135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.24
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA HMO/PPO	$1.24
Rate for Payer: Health Smart Auto/Commercial	$0.93
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.16

IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE [70544]

Facility

$100.00

Service Code	CPT J1740
Hospital Charge Code	1721133
Hospital Revenue Code	636
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$80.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna of CA HMO/PPO	$80.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE [70544]

Facility

$100.00

Service Code	CPT J1740
Hospital Charge Code	1721133
Hospital Revenue Code	636
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.00
Rate for Payer: Aetna of CA Government/Medicare	$60.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.16

Service Code	NDC 68094-503-62
Hospital Charge Code	NDG10246
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.19

Service Code	NDC 68094-494-61
Hospital Charge Code	1716048
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.08

Service Code	NDC 9994-2002-75
Hospital Charge Code	NDG10246
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.15

Service Code	NDC 0121-1828-00
Hospital Charge Code	NDG10246
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.19

Service Code	NDC 68094-494-61
Hospital Charge Code	1716048
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
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	$0.09
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 Beech St/Commercial/PHCS	$0.14

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.19

Service Code	NDC 68094-494-59
Hospital Charge Code	1716048
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.16

Service Code	NDC 68094-503-59
Hospital Charge Code	NDG10246
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.04

Service Code	NDC 24385-905-26
Hospital Charge Code	NDG10246B
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: 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 Beech St/Commercial/PHCS	$0.03

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.04

Service Code	NDC 24385-905-26
Hospital Charge Code	NDG10246B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.08

Service Code	NDC 9994-2002-74
Hospital Charge Code	1716048
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.08

Service Code	NDC 9994-2002-74
Hospital Charge Code	1716048
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.19

Service Code	NDC 68094-494-59
Hospital Charge Code	1716048
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
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	$0.09
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 Beech St/Commercial/PHCS	$0.14

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.15

Service Code	NDC 0121-1828-10
Hospital Charge Code	NDG10246
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.16

Service Code	NDC 68094-503-62
Hospital Charge Code	NDG10246
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

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]

Facility

$0.15

Service Code	NDC 0121-1828-10
Hospital Charge Code	NDG10246
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

Know your out-of-pocket cost for care.

All Charges