Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$2.50

Service Code	NDC 45802-368-00
Hospital Charge Code	1743682
Hospital Revenue Code	259
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.50
Rate for Payer: Aetna of CA Government/Medicare	$1.50
Rate for Payer: Cash Price	$1.13
Rate for Payer: Health Smart Auto/Commercial	$1.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.50
Rate for Payer: LLUH Dept of Risk Management WC	$1.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.88

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$7.50

Service Code	NDC 0168-0432-24
Hospital Charge Code	1743682
Hospital Revenue Code	259
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$5.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.50
Rate for Payer: Aetna of CA Government/Medicare	$4.50
Rate for Payer: Cash Price	$3.38
Rate for Payer: Health Smart Auto/Commercial	$4.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.50
Rate for Payer: LLUH Dept of Risk Management WC	$4.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.62

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$2.50

Service Code	NDC 45802-368-00
Hospital Charge Code	1743682
Hospital Revenue Code	259
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.00
Rate for Payer: Cash Price	$1.13
Rate for Payer: Cigna of CA HMO/PPO	$2.00
Rate for Payer: Health Smart Auto/Commercial	$1.50
Rate for Payer: LLUH Dept of Risk Management WC	$1.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.88

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$8.50

Service Code	NDC 99207-260-12
Hospital Charge Code	1743682
Hospital Revenue Code	259
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$6.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.10
Rate for Payer: Aetna of CA Government/Medicare	$5.10
Rate for Payer: Cash Price	$3.83
Rate for Payer: Health Smart Auto/Commercial	$5.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.10
Rate for Payer: LLUH Dept of Risk Management WC	$4.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.38

IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]

Facility

$8.50

Service Code	NDC 99207-260-12
Hospital Charge Code	1743682
Hospital Revenue Code	259
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$6.80
Rate for Payer: Cash Price	$3.83
Rate for Payer: Cigna of CA HMO/PPO	$6.80
Rate for Payer: Health Smart Auto/Commercial	$5.10
Rate for Payer: LLUH Dept of Risk Management WC	$4.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.38

IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]

Facility

$51.49

Service Code	CPT J1559
Hospital Charge Code	NDG108090
Hospital Revenue Code	636
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$38.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.89
Rate for Payer: Aetna of CA Government/Medicare	$30.89
Rate for Payer: Cash Price	$23.17
Rate for Payer: Health Smart Auto/Commercial	$30.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.89
Rate for Payer: LLUH Dept of Risk Management WC	$28.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.62

IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]

Facility

$51.49

Service Code	CPT J1559
Hospital Charge Code	NDG108090
Hospital Revenue Code	636
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$41.19
Rate for Payer: Cash Price	$23.17
Rate for Payer: Cigna of CA HMO/PPO	$41.19
Rate for Payer: Health Smart Auto/Commercial	$30.89
Rate for Payer: LLUH Dept of Risk Management WC	$28.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.62

IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]

Facility

$16.43

Service Code	CPT J1561
Hospital Charge Code	NDG107754
Hospital Revenue Code	636
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$13.14
Rate for Payer: Cash Price	$7.39
Rate for Payer: Cigna of CA HMO/PPO	$13.14
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.32

IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]

Facility

$16.43

Service Code	CPT J1561
Hospital Charge Code	NDG107754
Hospital Revenue Code	636
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$12.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.86
Rate for Payer: Aetna of CA Government/Medicare	$9.86
Rate for Payer: Cash Price	$7.39
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.32

IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]

Facility

$16.43

Service Code	CPT J1561
Hospital Charge Code	NDG207906
Hospital Revenue Code	636
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$13.14
Rate for Payer: Cash Price	$7.39
Rate for Payer: Cigna of CA HMO/PPO	$13.14
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.32

IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]

Facility

$16.43

Service Code	CPT J1561
Hospital Charge Code	NDG207906
Hospital Revenue Code	636
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$12.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.86
Rate for Payer: Aetna of CA Government/Medicare	$9.86
Rate for Payer: Cash Price	$7.39
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.32

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934B
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$14.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.62
Rate for Payer: Aetna of CA Government/Medicare	$11.62
Rate for Payer: Cash Price	$8.72
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$14.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.62
Rate for Payer: Aetna of CA Government/Medicare	$11.62
Rate for Payer: Cash Price	$8.72
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934D
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$15.50
Rate for Payer: Cash Price	$8.72
Rate for Payer: Cigna of CA HMO/PPO	$15.50
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934C
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$15.50
Rate for Payer: Cash Price	$8.72
Rate for Payer: Cigna of CA HMO/PPO	$15.50
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934C
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$14.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.62
Rate for Payer: Aetna of CA Government/Medicare	$11.62
Rate for Payer: Cash Price	$8.72
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	1759128
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$15.50
Rate for Payer: Cash Price	$8.72
Rate for Payer: Cigna of CA HMO/PPO	$15.50
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934D
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$14.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.62
Rate for Payer: Aetna of CA Government/Medicare	$11.62
Rate for Payer: Cash Price	$8.72
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	1759128
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$14.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.62
Rate for Payer: Aetna of CA Government/Medicare	$11.62
Rate for Payer: Cash Price	$8.72
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934B
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$15.50
Rate for Payer: Cash Price	$8.72
Rate for Payer: Cigna of CA HMO/PPO	$15.50
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]

Facility

$19.37

Service Code	CPT J1569
Hospital Charge Code	NDG209934
Hospital Revenue Code	636
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$15.50
Rate for Payer: Cash Price	$8.72
Rate for Payer: Cigna of CA HMO/PPO	$15.50
Rate for Payer: Health Smart Auto/Commercial	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$10.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.53

IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]

Facility

$2,587.56

Service Code	CPT J1566
Hospital Charge Code	NDG10258
Hospital Revenue Code	636
Min. Negotiated Rate	$1,423.16
Max. Negotiated Rate	$1,940.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,552.54
Rate for Payer: Aetna of CA Government/Medicare	$1,552.54
Rate for Payer: Cash Price	$1,164.40
Rate for Payer: Health Smart Auto/Commercial	$1,552.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,552.54
Rate for Payer: LLUH Dept of Risk Management WC	$1,423.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,940.67

IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]

Facility

$2,587.56

Service Code	CPT J1566
Hospital Charge Code	NDG10258
Hospital Revenue Code	636
Min. Negotiated Rate	$1,423.16
Max. Negotiated Rate	$2,070.05
Rate for Payer: Cash Price	$1,164.40
Rate for Payer: Cigna of CA HMO/PPO	$2,070.05
Rate for Payer: Health Smart Auto/Commercial	$1,552.54
Rate for Payer: LLUH Dept of Risk Management WC	$1,423.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,940.67

IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]

Facility

$22.41

Service Code	CPT J1568
Hospital Charge Code	NDG207352D
Hospital Revenue Code	636
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$16.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.45
Rate for Payer: Aetna of CA Government/Medicare	$13.45
Rate for Payer: Cash Price	$10.08
Rate for Payer: Health Smart Auto/Commercial	$13.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.45
Rate for Payer: LLUH Dept of Risk Management WC	$12.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.81

IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]

Facility

$22.41

Service Code	CPT J1568
Hospital Charge Code	NDG207352D
Hospital Revenue Code	636
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$17.93
Rate for Payer: Cash Price	$10.08
Rate for Payer: Cigna of CA HMO/PPO	$17.93
Rate for Payer: Health Smart Auto/Commercial	$13.45
Rate for Payer: LLUH Dept of Risk Management WC	$12.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.81

Know your out-of-pocket cost for care.

All Charges