Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BACLOFEN 20 MG TABLET [861]

Facility

$0.80

Service Code	NDC 0904-6476-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

BACLOFEN 20 MG TABLET [861]

Facility

$0.08

Service Code	NDC 59651-395-01
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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 Commercial	$0.06

BACLOFEN 20 MG TABLET [861]

Facility

$0.08

Service Code	NDC 59651-395-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$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: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

BACLOFEN 20 MG TABLET [861]

Facility

$0.13

Service Code	NDC 29300-344-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.10

BACLOFEN 20 MG TABLET [861]

Facility

$0.43

Service Code	NDC 0603-2407-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

BACLOFEN 20 MG TABLET [861]

Facility

$0.10

Service Code	NDC 70756-289-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
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: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

BACLOFEN 20 MG TABLET [861]

Facility

$0.14

Service Code	NDC 70710-1286-1
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

BACLOFEN 20 MG TABLET [861]

Facility

$0.14

Service Code	NDC 70710-1286-1
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

BACLOFEN 20 MG TABLET [861]

Facility

$0.13

Service Code	NDC 29300-344-01
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION [107800]

Facility

$61.81

Service Code	NDC 66794-157-02
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$49.45
Rate for Payer: Cash Price	$34.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.45
Rate for Payer: Health Smart Auto/Commercial	$37.09
Rate for Payer: LLUH Dept of Risk Management WC	$34.00
Rate for Payer: Multiplan Commercial	$46.36

BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION [107800]

Facility

$61.81

Service Code	NDC 66794-157-02
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$49.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.09
Rate for Payer: Aetna of CA Government/Medicare	$37.09
Rate for Payer: Cash Price	$34.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.45
Rate for Payer: Health Smart Auto/Commercial	$37.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.09
Rate for Payer: LLUH Dept of Risk Management WC	$34.00
Rate for Payer: Multiplan Commercial	$46.36

BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION [9209]

Facility

$14.18

Service Code	HCPCS J0475
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$11.34
Rate for Payer: Cash Price	$7.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.34
Rate for Payer: Health Smart Auto/Commercial	$8.51
Rate for Payer: LLUH Dept of Risk Management WC	$7.80
Rate for Payer: Multiplan Commercial	$10.63

BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION [9209]

Facility

$14.18

Service Code	HCPCS J0475
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$11.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.51
Rate for Payer: Aetna of CA Government/Medicare	$8.51
Rate for Payer: Cash Price	$7.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.34
Rate for Payer: Health Smart Auto/Commercial	$8.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.51
Rate for Payer: LLUH Dept of Risk Management WC	$7.80
Rate for Payer: Multiplan Commercial	$10.63

BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]

Facility

$39.56

Service Code	HCPCS J0476
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$21.76
Max. Negotiated Rate	$31.65
Rate for Payer: Cash Price	$21.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.65
Rate for Payer: Health Smart Auto/Commercial	$23.74
Rate for Payer: LLUH Dept of Risk Management WC	$21.76
Rate for Payer: Multiplan Commercial	$29.67

BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]

Facility

$39.56

Service Code	HCPCS J0476
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$21.76
Max. Negotiated Rate	$31.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.74
Rate for Payer: Aetna of CA Government/Medicare	$23.74
Rate for Payer: Cash Price	$21.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.65
Rate for Payer: Health Smart Auto/Commercial	$23.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.74
Rate for Payer: LLUH Dept of Risk Management WC	$21.76
Rate for Payer: Multiplan Commercial	$29.67

BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]

Facility

$0.27

Service Code	NDC 9994-0802-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
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	$0.22
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	$0.15
Rate for Payer: Multiplan Commercial	$0.20

BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]

Facility

$0.27

Service Code	NDC 9994-0802-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]

Facility

$0.25

Service Code	NDC 0065-0800-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]

Facility

$0.25

Service Code	NDC 0065-0800-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]

Facility

$0.09

Service Code	NDC 0065-1795-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.07

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]

Facility

$1.01

Service Code	NDC 0065-0795-15
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]

Facility

$0.09

Service Code	NDC 0065-1795-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
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	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
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 Commercial	$0.07

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]

Facility

$0.09

Service Code	NDC 0065-0795-50
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.07

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]

Facility

$0.09

Service Code	NDC 0065-0795-50
Hospital Charge Code	901700004
Hospital Revenue Code	250
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	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
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 Commercial	$0.07

BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]

Facility

$1.01

Service Code	NDC 0065-0795-15
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

Know your out-of-pocket cost for care.

All Charges