Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

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

Facility

$96.00

Service Code	NDC 81284-315-00
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

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	$76.80
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of CA HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.00

INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]

Facility

$4,608.00

Service Code	CPT A9572
Hospital Charge Code	ERX13545
Hospital Revenue Code	343
Min. Negotiated Rate	$2,534.40
Max. Negotiated Rate	$3,686.40
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Cigna of CA HMO/PPO	$3,686.40
Rate for Payer: Health Smart Auto/Commercial	$2,764.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,534.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,456.00

INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]

Facility

$4,608.00

Service Code	CPT A9572
Hospital Charge Code	ERX13545
Hospital Revenue Code	343
Min. Negotiated Rate	$2,534.40
Max. Negotiated Rate	$3,456.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,764.80
Rate for Payer: Aetna of CA Government/Medicare	$2,764.80
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Health Smart Auto/Commercial	$2,764.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,764.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,534.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,456.00

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$136.72

Service Code	NDC 17478-701-25
Hospital Charge Code	1720205
Hospital Revenue Code	250
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$102.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$82.03
Rate for Payer: Aetna of CA Government/Medicare	$82.03
Rate for Payer: Cash Price	$61.52
Rate for Payer: Health Smart Auto/Commercial	$82.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$82.03
Rate for Payer: LLUH Dept of Risk Management WC	$75.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$102.54

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$136.72

Service Code	NDC 17478-701-02
Hospital Charge Code	1720205
Hospital Revenue Code	250
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$109.38
Rate for Payer: Cash Price	$61.52
Rate for Payer: Cigna of CA HMO/PPO	$109.38
Rate for Payer: Health Smart Auto/Commercial	$82.03
Rate for Payer: LLUH Dept of Risk Management WC	$75.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$102.54

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$136.72

Service Code	NDC 17478-701-25
Hospital Charge Code	1720205
Hospital Revenue Code	250
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$109.38
Rate for Payer: Cash Price	$61.52
Rate for Payer: Cigna of CA HMO/PPO	$109.38
Rate for Payer: Health Smart Auto/Commercial	$82.03
Rate for Payer: LLUH Dept of Risk Management WC	$75.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$102.54

INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]

Facility

$136.72

Service Code	NDC 17478-701-02
Hospital Charge Code	1720205
Hospital Revenue Code	250
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$102.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$82.03
Rate for Payer: Aetna of CA Government/Medicare	$82.03
Rate for Payer: Cash Price	$61.52
Rate for Payer: Health Smart Auto/Commercial	$82.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$82.03
Rate for Payer: LLUH Dept of Risk Management WC	$75.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$102.54

INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]

Facility

$445.49

Service Code	NDC 63323-659-94
Hospital Charge Code	1753530
Hospital Revenue Code	250
Min. Negotiated Rate	$245.02
Max. Negotiated Rate	$334.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$267.29
Rate for Payer: Aetna of CA Government/Medicare	$267.29
Rate for Payer: Cash Price	$200.47
Rate for Payer: Health Smart Auto/Commercial	$267.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$267.29
Rate for Payer: LLUH Dept of Risk Management WC	$245.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$334.12

INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]

Facility

$445.49

Service Code	NDC 63323-659-94
Hospital Charge Code	1753530
Hospital Revenue Code	250
Min. Negotiated Rate	$245.02
Max. Negotiated Rate	$356.39
Rate for Payer: Cash Price	$200.47
Rate for Payer: Cigna of CA HMO/PPO	$356.39
Rate for Payer: Health Smart Auto/Commercial	$267.29
Rate for Payer: LLUH Dept of Risk Management WC	$245.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$334.12

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-11
Hospital Charge Code	1710358
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-11
Hospital Charge Code	1710358
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.26

Service Code	NDC 68462-406-01
Hospital Charge Code	1710358
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
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	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-15
Hospital Charge Code	1710358
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.26

Service Code	NDC 68462-406-01
Hospital Charge Code	1710358
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

INDOMETHACIN 25 MG CAPSULE [3897]

Facility

$0.43

Service Code	NDC 50268-430-15
Hospital Charge Code	1710358
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.39

Service Code	NDC 50268-431-11
Hospital Charge Code	1710382
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.39

Service Code	NDC 50268-431-11
Hospital Charge Code	1710382
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.33

Service Code	NDC 68462-302-01
Hospital Charge Code	1710382
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

INDOMETHACIN 50 MG CAPSULE [3898]

Facility

$0.33

Service Code	NDC 68462-302-01
Hospital Charge Code	1710382
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$434.29

Service Code	NDC 69344-102-33
Hospital Charge Code	1748065
Hospital Revenue Code	259
Min. Negotiated Rate	$238.86
Max. Negotiated Rate	$347.43
Rate for Payer: Cash Price	$195.43
Rate for Payer: Cigna of CA HMO/PPO	$347.43
Rate for Payer: Health Smart Auto/Commercial	$260.57
Rate for Payer: LLUH Dept of Risk Management WC	$238.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$325.72

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$434.29

Service Code	NDC 69344-102-33
Hospital Charge Code	1748065
Hospital Revenue Code	259
Min. Negotiated Rate	$238.86
Max. Negotiated Rate	$325.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$260.57
Rate for Payer: Aetna of CA Government/Medicare	$260.57
Rate for Payer: Cash Price	$195.43
Rate for Payer: Health Smart Auto/Commercial	$260.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$260.57
Rate for Payer: LLUH Dept of Risk Management WC	$238.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$325.72

INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]

Facility

$0.42

Service Code	NDC 68462-325-60
Hospital Charge Code	1710396
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]

Facility

$0.42

Service Code	NDC 68462-325-60
Hospital Charge Code	1710396
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

Know your out-of-pocket cost for care.

All Charges