Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MILRINONE 40 MG/200 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK [119863]

Facility

$0.18

Service Code	HCPCS J2260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14
Rate for Payer: Multiplan Commercial	$0.14

MILRINONE 40 MG/200 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK [119863]

Facility

$0.18

Service Code	HCPCS J2260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14
Rate for Payer: Multiplan Commercial	$0.14

MILRINONE 5 MG/50 ML D5.2NS SYRINGE [4080686]

Facility

$42.93

Service Code	HCPCS J2260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$23.61
Max. Negotiated Rate	$34.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.76
Rate for Payer: Aetna of CA Government/Medicare	$25.76
Rate for Payer: Cash Price	$23.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$34.34
Rate for Payer: Health Smart Auto/Commercial	$25.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.76
Rate for Payer: LLUH Dept of Risk Management WC	$23.61
Rate for Payer: Multiplan Commercial	$32.20

MILRINONE 5 MG/50 ML D5.2NS SYRINGE [4080686]

Facility

$42.93

Service Code	HCPCS J2260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$23.61
Max. Negotiated Rate	$34.34
Rate for Payer: Cash Price	$23.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$34.34
Rate for Payer: Health Smart Auto/Commercial	$25.76
Rate for Payer: LLUH Dept of Risk Management WC	$23.61
Rate for Payer: Multiplan Commercial	$32.20

MINERAL OIL ENEMA [5087]

Facility

$0.02

Service Code	NDC 0132-0301-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

MINERAL OIL ENEMA [5087]

Facility

$0.02

Service Code	NDC 0132-0301-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

MINERAL OIL, LIGHT STERILE [226645]

Facility

$11.83

Service Code	NDC 6332325402
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$9.46
Rate for Payer: Cash Price	$6.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.46
Rate for Payer: Health Smart Auto/Commercial	$7.10
Rate for Payer: LLUH Dept of Risk Management WC	$6.51
Rate for Payer: Multiplan Commercial	$8.87

MINERAL OIL, LIGHT STERILE [226645]

Facility

$11.83

Service Code	NDC 6332325402
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$9.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.10
Rate for Payer: Aetna of CA Government/Medicare	$7.10
Rate for Payer: Cash Price	$6.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.46
Rate for Payer: Health Smart Auto/Commercial	$7.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.10
Rate for Payer: LLUH Dept of Risk Management WC	$6.51
Rate for Payer: Multiplan Commercial	$8.87

MINERAL OIL, LIGHT STERILE [226645]

Facility

$2.73

Service Code	NDC 6332325410
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.18
Rate for Payer: Cash Price	$1.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.18
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.50
Rate for Payer: Multiplan Commercial	$2.05

MINERAL OIL, LIGHT STERILE [226645]

Facility

$2.73

Service Code	NDC 6332325410
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.64
Rate for Payer: Aetna of CA Government/Medicare	$1.64
Rate for Payer: Cash Price	$1.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.18
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.50
Rate for Payer: Multiplan Commercial	$2.05

MINERAL OIL ORAL [5086]

Facility

$0.07

Service Code	NDC 48433-202-30
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	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

MINERAL OIL ORAL [5086]

Facility

$0.01

Service Code	NDC 46122-395-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

MINERAL OIL ORAL [5086]

Facility

$0.07

Service Code	NDC 48433-202-30
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	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
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	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

MINERAL OIL ORAL [5086]

Facility

$0.01

Service Code	NDC 46122-395-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$1.32

Service Code	NDC 60687-336-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$0.67

Service Code	NDC 0591-5695-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$1.32

Service Code	NDC 60687-336-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$0.67

Service Code	NDC 57664-853-85
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$0.67

Service Code	NDC 0591-5695-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$1.32

Service Code	NDC 60687-336-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$0.67

Service Code	NDC 65862-211-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$0.67

Service Code	NDC 65862-211-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$0.67

Service Code	NDC 57664-853-85
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

MINOCYCLINE 100 MG CAPSULE [5110]

Facility

$1.32

Service Code	NDC 60687-336-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]

Facility

$310.20

Service Code	HCPCS J2265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$170.61
Max. Negotiated Rate	$248.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$186.12
Rate for Payer: Aetna of CA Government/Medicare	$186.12
Rate for Payer: Cash Price	$170.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$248.16
Rate for Payer: Health Smart Auto/Commercial	$186.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$186.12
Rate for Payer: LLUH Dept of Risk Management WC	$170.61
Rate for Payer: Multiplan Commercial	$232.65

Know your out-of-pocket cost for care.

All Charges