Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.16

Service Code	NDC 64380-807-06
Hospital Charge Code	1711405
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 800 MG TABLET [3845]

Facility

$0.09

Service Code	NDC 0904-5855-61
Hospital Charge Code	1711405
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

IBUPROFEN 800 MG TABLET [3845]

Facility

$0.15

Service Code	NDC 0904-5855-60
Hospital Charge Code	1711405
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

IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [76780]

Facility

$273.74

Service Code	CPT J1741
Hospital Charge Code	1721169
Hospital Revenue Code	636
Min. Negotiated Rate	$150.56
Max. Negotiated Rate	$205.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$164.24
Rate for Payer: Aetna of CA Government/Medicare	$164.24
Rate for Payer: Cash Price	$123.18
Rate for Payer: Health Smart Auto/Commercial	$164.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$164.24
Rate for Payer: LLUH Dept of Risk Management WC	$150.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$205.30

IBUPROFEN LYSINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION [76780]

Facility

$273.74

Service Code	CPT J1741
Hospital Charge Code	1721169
Hospital Revenue Code	636
Min. Negotiated Rate	$150.56
Max. Negotiated Rate	$218.99
Rate for Payer: Cash Price	$123.18
Rate for Payer: Cigna of CA HMO/PPO	$218.99
Rate for Payer: Health Smart Auto/Commercial	$164.24
Rate for Payer: LLUH Dept of Risk Management WC	$150.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$205.30

IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION [16156]

Facility

$65.86

Service Code	CPT J1742
Hospital Charge Code	1722011
Hospital Revenue Code	636
Min. Negotiated Rate	$36.22
Max. Negotiated Rate	$52.69
Rate for Payer: Cash Price	$29.64
Rate for Payer: Cigna of CA HMO/PPO	$52.69
Rate for Payer: Health Smart Auto/Commercial	$39.52
Rate for Payer: LLUH Dept of Risk Management WC	$36.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.40

IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION [16156]

Facility

$65.86

Service Code	CPT J1742
Hospital Charge Code	1722011
Hospital Revenue Code	636
Min. Negotiated Rate	$36.22
Max. Negotiated Rate	$49.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.52
Rate for Payer: Aetna of CA Government/Medicare	$39.52
Rate for Payer: Cash Price	$29.64
Rate for Payer: Health Smart Auto/Commercial	$39.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.52
Rate for Payer: LLUH Dept of Risk Management WC	$36.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.40

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$16.07

Service Code	CPT J9211
Hospital Charge Code	NDG22144B
Hospital Revenue Code	636
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$12.86
Rate for Payer: Cash Price	$7.23
Rate for Payer: Cigna of CA HMO/PPO	$12.86
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.05

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$12.94

Service Code	CPT J9211
Hospital Charge Code	NDG22144A
Hospital Revenue Code	636
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$9.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.76
Rate for Payer: Aetna of CA Government/Medicare	$7.76
Rate for Payer: Cash Price	$5.82
Rate for Payer: Health Smart Auto/Commercial	$7.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.76
Rate for Payer: LLUH Dept of Risk Management WC	$7.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.70

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$12.42

Service Code	CPT J9211
Hospital Charge Code	1755541
Hospital Revenue Code	636
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$9.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.45
Rate for Payer: Aetna of CA Government/Medicare	$7.45
Rate for Payer: Cash Price	$5.59
Rate for Payer: Health Smart Auto/Commercial	$7.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.45
Rate for Payer: LLUH Dept of Risk Management WC	$6.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.32

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$16.07

Service Code	CPT J9211
Hospital Charge Code	NDG22144B
Hospital Revenue Code	636
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$12.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.64
Rate for Payer: Aetna of CA Government/Medicare	$9.64
Rate for Payer: Cash Price	$7.23
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.64
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.05

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$12.94

Service Code	CPT J9211
Hospital Charge Code	NDG22144A
Hospital Revenue Code	636
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$10.35
Rate for Payer: Cash Price	$5.82
Rate for Payer: Cigna of CA HMO/PPO	$10.35
Rate for Payer: Health Smart Auto/Commercial	$7.76
Rate for Payer: LLUH Dept of Risk Management WC	$7.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.70

IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION [22144]

Facility

$12.42

Service Code	CPT J9211
Hospital Charge Code	1755541
Hospital Revenue Code	636
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$9.94
Rate for Payer: Cash Price	$5.59
Rate for Payer: Cigna of CA HMO/PPO	$9.94
Rate for Payer: Health Smart Auto/Commercial	$7.45
Rate for Payer: LLUH Dept of Risk Management WC	$6.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.32

IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [211698]

Facility

$56.61

Service Code	CPT J3590
Hospital Charge Code	NDG211698
Hospital Revenue Code	636
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$42.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.97
Rate for Payer: Aetna of CA Government/Medicare	$33.97
Rate for Payer: Cash Price	$25.47
Rate for Payer: Health Smart Auto/Commercial	$33.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.97
Rate for Payer: LLUH Dept of Risk Management WC	$31.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.46

IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [211698]

Facility

$56.61

Service Code	CPT J3590
Hospital Charge Code	NDG211698
Hospital Revenue Code	636
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$45.29
Rate for Payer: Cash Price	$25.47
Rate for Payer: Cigna of CA HMO/PPO	$45.29
Rate for Payer: Health Smart Auto/Commercial	$33.97
Rate for Payer: LLUH Dept of Risk Management WC	$31.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.46

IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION [87925]

Facility

$2.20

Service Code	CPT J9208
Hospital Charge Code	NDG87925
Hospital Revenue Code	636
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.32
Rate for Payer: Aetna of CA Government/Medicare	$1.32
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Smart Auto/Commercial	$1.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.65

IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION [87925]

Facility

$2.20

Service Code	CPT J9208
Hospital Charge Code	NDG87925
Hospital Revenue Code	636
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.76
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of CA HMO/PPO	$1.76
Rate for Payer: Health Smart Auto/Commercial	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.65

IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION [10248]

Facility

$44.09

Service Code	CPT J9208
Hospital Charge Code	1755702
Hospital Revenue Code	636
Min. Negotiated Rate	$24.25
Max. Negotiated Rate	$33.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$26.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.80
Rate for Payer: Aetna of CA Government/Medicare	$26.45
Rate for Payer: Aetna of CA Government/Medicare	$41.80
Rate for Payer: Cash Price	$31.35
Rate for Payer: Cash Price	$19.84
Rate for Payer: Health Smart Auto/Commercial	$41.80
Rate for Payer: Health Smart Auto/Commercial	$26.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$26.45
Rate for Payer: LLUH Dept of Risk Management WC	$24.25
Rate for Payer: LLUH Dept of Risk Management WC	$38.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.24

IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION [10248]

Facility

$44.09

Service Code	CPT J9208
Hospital Charge Code	1755702
Hospital Revenue Code	636
Min. Negotiated Rate	$24.25
Max. Negotiated Rate	$35.27
Rate for Payer: Cash Price	$19.84
Rate for Payer: Cash Price	$31.35
Rate for Payer: Cigna of CA HMO/PPO	$35.27
Rate for Payer: Cigna of CA HMO/PPO	$55.73
Rate for Payer: Health Smart Auto/Commercial	$26.45
Rate for Payer: Health Smart Auto/Commercial	$41.80
Rate for Payer: LLUH Dept of Risk Management WC	$38.31
Rate for Payer: LLUH Dept of Risk Management WC	$24.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.24

IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION [87926]

Facility

$2.15

Service Code	CPT J9208
Hospital Charge Code	NDG87926
Hospital Revenue Code	636
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.29
Rate for Payer: Aetna of CA Government/Medicare	$1.29
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Smart Auto/Commercial	$1.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.29
Rate for Payer: LLUH Dept of Risk Management WC	$1.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.61

IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION [87926]

Facility

$2.15

Service Code	CPT J9208
Hospital Charge Code	NDG87926
Hospital Revenue Code	636
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.72
Rate for Payer: Cash Price	$0.97
Rate for Payer: Cigna of CA HMO/PPO	$1.72
Rate for Payer: Health Smart Auto/Commercial	$1.29
Rate for Payer: LLUH Dept of Risk Management WC	$1.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.61

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$129.05

Service Code	CPT J9208
Hospital Charge Code	1755703
Hospital Revenue Code	636
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$103.24
Rate for Payer: Cash Price	$58.07
Rate for Payer: Cigna of CA HMO/PPO	$103.24
Rate for Payer: Health Smart Auto/Commercial	$77.43
Rate for Payer: LLUH Dept of Risk Management WC	$70.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$96.79

IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]

Facility

$129.05

Service Code	CPT J9208
Hospital Charge Code	1755703
Hospital Revenue Code	636
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$96.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$77.43
Rate for Payer: Aetna of CA Government/Medicare	$77.43
Rate for Payer: Cash Price	$58.07
Rate for Payer: Health Smart Auto/Commercial	$77.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$77.43
Rate for Payer: LLUH Dept of Risk Management WC	$70.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$96.79

ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]

Facility

$161.64

Service Code	NDC 66215-302-30
Hospital Charge Code	1744129
Hospital Revenue Code	259
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$121.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.98
Rate for Payer: Aetna of CA Government/Medicare	$96.98
Rate for Payer: Cash Price	$72.74
Rate for Payer: Health Smart Auto/Commercial	$96.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$96.98
Rate for Payer: LLUH Dept of Risk Management WC	$88.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.23

ILOPROST 10 MCG/ML SOLUTION FOR NEBULIZATION [40413]

Facility

$161.64

Service Code	NDC 66215-302-00
Hospital Charge Code	1744129
Hospital Revenue Code	259
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$129.31
Rate for Payer: Cash Price	$72.74
Rate for Payer: Cigna of CA HMO/PPO	$129.31
Rate for Payer: Health Smart Auto/Commercial	$96.98
Rate for Payer: LLUH Dept of Risk Management WC	$88.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.23

Know your out-of-pocket cost for care.

All Charges