Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]

Facility

$162.23

Service Code	HCPCS J9280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$89.23
Max. Negotiated Rate	$129.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$455.03
Rate for Payer: Aetna of CA Government/Medicare	$455.03
Rate for Payer: Aetna of CA Government/Medicare	$97.34
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	$97.34
Rate for Payer: Health Smart Auto/Commercial	$455.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$455.03
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	$568.78
Rate for Payer: Multiplan Commercial	$121.67

MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]

Facility

$291.92

Service Code	HCPCS J9280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$160.56
Max. Negotiated Rate	$233.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$175.15
Rate for Payer: Aetna of CA Government/Medicare	$175.15
Rate for Payer: Cash Price	$160.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$233.54
Rate for Payer: Health Smart Auto/Commercial	$175.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$175.15
Rate for Payer: LLUH Dept of Risk Management WC	$160.56
Rate for Payer: Multiplan Commercial	$218.94

MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]

Facility

$291.92

Service Code	HCPCS J9280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$160.56
Max. Negotiated Rate	$233.54
Rate for Payer: Cash Price	$160.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$233.54
Rate for Payer: Health Smart Auto/Commercial	$175.15
Rate for Payer: LLUH Dept of Risk Management WC	$160.56
Rate for Payer: Multiplan Commercial	$218.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.95
Rate for Payer: Aetna of CA Government/Medicare	$7.95
Rate for Payer: Cash Price	$7.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.60
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Commercial	$9.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.60
Rate for Payer: Cash Price	$7.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.60
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Commercial	$9.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.95
Rate for Payer: Aetna of CA Government/Medicare	$7.95
Rate for Payer: Cash Price	$7.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.60
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Commercial	$9.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.60
Rate for Payer: Cash Price	$7.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.60
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Commercial	$9.94

MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]

Facility

$142.55

Service Code	NDC 9994-0807-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$114.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.53
Rate for Payer: Aetna of CA Government/Medicare	$85.53
Rate for Payer: Cash Price	$78.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$114.04
Rate for Payer: Health Smart Auto/Commercial	$85.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.53
Rate for Payer: LLUH Dept of Risk Management WC	$78.40
Rate for Payer: Multiplan Commercial	$106.91

MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]

Facility

$142.55

Service Code	NDC 9994-0807-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$114.04
Rate for Payer: Cash Price	$78.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$114.04
Rate for Payer: Health Smart Auto/Commercial	$85.53
Rate for Payer: LLUH Dept of Risk Management WC	$78.40
Rate for Payer: Multiplan Commercial	$106.91

MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]

Facility

$1.43

Service Code	NDC 9994-0810-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.07

MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]

Facility

$1.43

Service Code	NDC 9994-0810-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.07

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$20.71

Service Code	HCPCS J9293
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$16.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.60
Rate for Payer: Aetna of CA Government/Medicare	$30.60
Rate for Payer: Aetna of CA Government/Medicare	$12.43
Rate for Payer: Cash Price	$28.05
Rate for Payer: Cash Price	$11.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.80
Rate for Payer: Health Smart Auto/Commercial	$12.43
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.39
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Commercial	$38.25
Rate for Payer: Multiplan Commercial	$15.53

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$51.00

Service Code	HCPCS J9293
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$40.80
Rate for Payer: Cash Price	$28.05
Rate for Payer: Cash Price	$11.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.80
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Health Smart Auto/Commercial	$12.43
Rate for Payer: LLUH Dept of Risk Management WC	$11.39
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Commercial	$15.53
Rate for Payer: Multiplan Commercial	$38.25

MODAFINIL 100 MG TABLET [24702]

Facility

$13.20

Service Code	NDC 68084-621-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

MODAFINIL 100 MG TABLET [24702]

Facility

$0.36

Service Code	NDC 69452-342-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

MODAFINIL 100 MG TABLET [24702]

Facility

$13.20

Service Code	NDC 68084-621-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

MODAFINIL 100 MG TABLET [24702]

Facility

$13.20

Service Code	NDC 68084-621-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

MODAFINIL 100 MG TABLET [24702]

Facility

$13.20

Service Code	NDC 68084-621-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

MODAFINIL 100 MG TABLET [24702]

Facility

$0.36

Service Code	NDC 69452-342-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

MODIFIED LANOLIN 100 % TOPICAL CREAM [225322]

Facility

$0.20

Service Code	NDC 4467710020
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

MODIFIED LANOLIN 100 % TOPICAL CREAM [225322]

Facility

$0.20

Service Code	NDC 4467710020
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

MOMETASONE 0.1 % TOPICAL OINTMENT [10648]

Facility

$0.78

Service Code	NDC 45802-119-42
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

MOMETASONE 0.1 % TOPICAL OINTMENT [10648]

Facility

$0.78

Service Code	NDC 45802-119-42
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

MONTELUKAST 10 MG TABLET [22509]

Facility

$0.40

Service Code	NDC 0904-6808-61
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

MONTELUKAST 10 MG TABLET [22509]

Facility

$0.10

Service Code	NDC 16729-119-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

Know your out-of-pocket cost for care.

All Charges