Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MIRTAZAPINE 30 MG TABLET [17465]

Facility

$0.40

Service Code	NDC 68084-120-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

MIRTAZAPINE 30 MG TABLET [17465]

Facility

$0.40

Service Code	NDC 68084-120-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 9999-9384-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.05
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.92

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$1.30

Service Code	NDC 13107-001-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.49

Service Code	NDC 57664-510-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.49
Rate for Payer: Aetna of CA Government/Medicare	$1.49
Rate for Payer: Cash Price	$1.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.99
Rate for Payer: Health Smart Auto/Commercial	$1.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.49
Rate for Payer: LLUH Dept of Risk Management WC	$1.37
Rate for Payer: Multiplan Commercial	$1.87

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.49

Service Code	NDC 57664-510-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.99
Rate for Payer: Cash Price	$1.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.99
Rate for Payer: Health Smart Auto/Commercial	$1.49
Rate for Payer: LLUH Dept of Risk Management WC	$1.37
Rate for Payer: Multiplan Commercial	$1.87

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 9999-9384-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.05
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.05
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.92

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$1.30

Service Code	NDC 13107-001-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 66993-606-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.05
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.92

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 66993-606-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.05
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.05
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.92

MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]

Facility

$406.94

Service Code	HCPCS J9063
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$223.82
Max. Negotiated Rate	$325.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$244.16
Rate for Payer: Aetna of CA Government/Medicare	$244.16
Rate for Payer: Cash Price	$223.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$325.55
Rate for Payer: Health Smart Auto/Commercial	$244.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$244.16
Rate for Payer: LLUH Dept of Risk Management WC	$223.82
Rate for Payer: Multiplan Commercial	$305.20

MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]

Facility

$406.94

Service Code	HCPCS J9063
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$223.82
Max. Negotiated Rate	$325.55
Rate for Payer: Cash Price	$223.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$325.55
Rate for Payer: Health Smart Auto/Commercial	$244.16
Rate for Payer: LLUH Dept of Risk Management WC	$223.82
Rate for Payer: Multiplan Commercial	$305.20

MISOPROSTOL 100 MCG TABLET [10628]

Facility

$0.80

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

MISOPROSTOL 100 MCG TABLET [10628]

Facility

$0.80

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

MISOPROSTOL 100MCGX10TABLET KIT [4081172]

Facility

$9.88

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$7.90
Rate for Payer: Cash Price	$5.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.90
Rate for Payer: Health Smart Auto/Commercial	$5.93
Rate for Payer: LLUH Dept of Risk Management WC	$5.43
Rate for Payer: Multiplan Commercial	$7.41

MISOPROSTOL 100MCGX10TABLET KIT [4081172]

Facility

$9.88

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$7.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.93
Rate for Payer: Aetna of CA Government/Medicare	$5.93
Rate for Payer: Cash Price	$5.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.90
Rate for Payer: Health Smart Auto/Commercial	$5.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.93
Rate for Payer: LLUH Dept of Risk Management WC	$5.43
Rate for Payer: Multiplan Commercial	$7.41

MISOPROSTOL 200 MCG TABLET [10629]

Facility

$1.16

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

MISOPROSTOL 200 MCG TABLET [10629]

Facility

$1.16

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

MISOPROSTOL 200MCGX5TABLET KIT [4081585]

Facility

$6.00

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

MISOPROSTOL 200MCGX5TABLET KIT [4081585]

Facility

$6.00

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

MISOPROSTOL 25 MCG 1/4 TAB [4080523]

Facility

$0.62

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

MISOPROSTOL 25 MCG 1/4 TAB [4080523]

Facility

$0.62

Service Code	HCPCS S0191
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]

Facility

$430.80

Service Code	HCPCS J7315
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$236.94
Max. Negotiated Rate	$344.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$258.48
Rate for Payer: Aetna of CA Government/Medicare	$258.48
Rate for Payer: Cash Price	$236.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$344.64
Rate for Payer: Health Smart Auto/Commercial	$258.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$258.48
Rate for Payer: LLUH Dept of Risk Management WC	$236.94
Rate for Payer: Multiplan Commercial	$323.10

MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]

Facility

$430.80

Service Code	HCPCS J7315
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$236.94
Max. Negotiated Rate	$344.64
Rate for Payer: Cash Price	$236.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$344.64
Rate for Payer: Health Smart Auto/Commercial	$258.48
Rate for Payer: LLUH Dept of Risk Management WC	$236.94
Rate for Payer: Multiplan Commercial	$323.10

MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]

Facility

$758.38

Service Code	HCPCS J9280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$417.11
Max. Negotiated Rate	$606.70
Rate for Payer: Cash Price	$417.11
Rate for Payer: Cash Price	$89.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$606.70
Rate for Payer: Health Smart Auto/Commercial	$455.03
Rate for Payer: Health Smart Auto/Commercial	$97.34
Rate for Payer: LLUH Dept of Risk Management WC	$89.23
Rate for Payer: LLUH Dept of Risk Management WC	$417.11
Rate for Payer: Multiplan Commercial	$121.67
Rate for Payer: Multiplan Commercial	$568.78

Know your out-of-pocket cost for care.

All Charges