Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$20.50

Service Code	CPT J1459
Hospital Charge Code	NDG209935A
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$16.40
Rate for Payer: Cash Price	$9.23
Rate for Payer: Cigna of CA HMO/PPO	$16.40
Rate for Payer: Health Smart Auto/Commercial	$12.30
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.38

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$20.50

Service Code	CPT J1459
Hospital Charge Code	NDG209935A
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$15.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.30
Rate for Payer: Aetna of CA Government/Medicare	$12.30
Rate for Payer: Cash Price	$9.23
Rate for Payer: Health Smart Auto/Commercial	$12.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.30
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.38

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$20.50

Service Code	CPT J1459
Hospital Charge Code	NDG108088C
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$16.40
Rate for Payer: Cash Price	$9.23
Rate for Payer: Cigna of CA HMO/PPO	$16.40
Rate for Payer: Health Smart Auto/Commercial	$12.30
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.38

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$20.50

Service Code	CPT J1459
Hospital Charge Code	NDG209935
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$15.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.30
Rate for Payer: Aetna of CA Government/Medicare	$12.30
Rate for Payer: Cash Price	$9.23
Rate for Payer: Health Smart Auto/Commercial	$12.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.30
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.38

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$20.50

Service Code	CPT J1459
Hospital Charge Code	NDG108088C
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$15.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.30
Rate for Payer: Aetna of CA Government/Medicare	$12.30
Rate for Payer: Cash Price	$9.23
Rate for Payer: Health Smart Auto/Commercial	$12.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.30
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.38

IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]

Facility

$20.50

Service Code	CPT J1459
Hospital Charge Code	NDG209935
Hospital Revenue Code	636
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$16.40
Rate for Payer: Health Smart Auto/Commercial	$12.30
Rate for Payer: Cash Price	$9.23
Rate for Payer: Cigna of CA HMO/PPO	$16.40
Rate for Payer: LLUH Dept of Risk Management WC	$11.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.38

IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]

Facility

$11.21

Service Code	CPT J1568
Hospital Charge Code	NDG210297B
Hospital Revenue Code	636
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.73
Rate for Payer: Aetna of CA Government/Medicare	$6.73
Rate for Payer: Cash Price	$5.04
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.41

IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]

Facility

$11.21

Service Code	CPT J1568
Hospital Charge Code	NDG210297B
Hospital Revenue Code	636
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.97
Rate for Payer: Cash Price	$5.04
Rate for Payer: Cigna of CA HMO/PPO	$8.97
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.41

IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]

Facility

$16.43

Service Code	CPT J1561
Hospital Charge Code	NDG107752
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 GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]

Facility

$16.43

Service Code	CPT J1561
Hospital Charge Code	NDG107752
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

INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]

Facility

$2,665.41

Service Code	CPT J1306
Hospital Charge Code	ERX233001
Hospital Revenue Code	636
Min. Negotiated Rate	$1,465.98
Max. Negotiated Rate	$2,132.33
Rate for Payer: Health Smart Auto/Commercial	$1,599.25
Rate for Payer: Cash Price	$1,199.43
Rate for Payer: Cigna of CA HMO/PPO	$2,132.33
Rate for Payer: LLUH Dept of Risk Management WC	$1,465.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,999.06

INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]

Facility

$2,665.41

Service Code	CPT J1306
Hospital Charge Code	ERX233001
Hospital Revenue Code	636
Min. Negotiated Rate	$1,465.98
Max. Negotiated Rate	$1,999.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,599.25
Rate for Payer: Aetna of CA Government/Medicare	$1,599.25
Rate for Payer: Cash Price	$1,199.43
Rate for Payer: Health Smart Auto/Commercial	$1,599.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,599.25
Rate for Payer: LLUH Dept of Risk Management WC	$1,465.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,999.06

INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]

Facility

$595.20

Service Code	CPT J0588
Hospital Charge Code	ERX105971
Hospital Revenue Code	636
Min. Negotiated Rate	$327.36
Max. Negotiated Rate	$476.16
Rate for Payer: Cash Price	$267.84
Rate for Payer: Cigna of CA HMO/PPO	$476.16
Rate for Payer: Health Smart Auto/Commercial	$357.12
Rate for Payer: LLUH Dept of Risk Management WC	$327.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$446.40

INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]

Facility

$595.20

Service Code	CPT J0588
Hospital Charge Code	ERX105971
Hospital Revenue Code	636
Min. Negotiated Rate	$327.36
Max. Negotiated Rate	$446.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$357.12
Rate for Payer: Aetna of CA Government/Medicare	$357.12
Rate for Payer: Cash Price	$267.84
Rate for Payer: Health Smart Auto/Commercial	$357.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$357.12
Rate for Payer: LLUH Dept of Risk Management WC	$327.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$446.40

INDAPAMIDE 2.5 MG TABLET [3879]

Facility

$0.74

Service Code	NDC 51079-868-01
Hospital Charge Code	1710672
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

INDAPAMIDE 2.5 MG TABLET [3879]

Facility

$0.74

Service Code	NDC 51079-868-01
Hospital Charge Code	1710672
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]

Facility

$45.22

Service Code	NDC 0517-0375-01
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$33.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.13
Rate for Payer: Aetna of CA Government/Medicare	$27.13
Rate for Payer: Cash Price	$20.35
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]

Facility

$45.22

Service Code	NDC 0517-0375-05
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$33.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.13
Rate for Payer: Aetna of CA Government/Medicare	$27.13
Rate for Payer: Cash Price	$20.35
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]

Facility

$45.22

Service Code	NDC 0517-0375-05
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$36.18
Rate for Payer: Cash Price	$20.35
Rate for Payer: Cigna of CA HMO/PPO	$36.18
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]

Facility

$45.22

Service Code	NDC 0517-0375-01
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$36.18
Rate for Payer: Cash Price	$20.35
Rate for Payer: Cigna of CA HMO/PPO	$36.18
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]

Facility

$45.22

Service Code	NDC 0517-0375-05
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$36.18
Rate for Payer: Cash Price	$20.35
Rate for Payer: Cigna of CA HMO/PPO	$36.18
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]

Facility

$45.22

Service Code	NDC 0517-0375-05
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$33.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.13
Rate for Payer: Aetna of CA Government/Medicare	$27.13
Rate for Payer: Cash Price	$20.35
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]

Facility

$45.22

Service Code	NDC 0517-0375-01
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$36.18
Rate for Payer: Cash Price	$20.35
Rate for Payer: Cigna of CA HMO/PPO	$36.18
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]

Facility

$45.22

Service Code	NDC 0517-0375-01
Hospital Charge Code	1720070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$33.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.13
Rate for Payer: Aetna of CA Government/Medicare	$27.13
Rate for Payer: Cash Price	$20.35
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.13
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]

Facility

$96.00

Service Code	NDC 81284-315-05
Hospital Charge Code	NDG235583
Hospital Revenue Code	250
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.60
Rate for Payer: Aetna of CA Government/Medicare	$57.60
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.00

Know your out-of-pocket cost for care.

All Charges