Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]

Facility

$0.26

Service Code	NDC 62175-119-37
Hospital Charge Code	1711622
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

ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]

Facility

$150.96

Service Code	CPT Q9968
Hospital Charge Code	1721183
Hospital Revenue Code	636
Min. Negotiated Rate	$83.03
Max. Negotiated Rate	$113.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$152.77
Rate for Payer: Aetna of CA Government/Medicare	$90.58
Rate for Payer: Aetna of CA Government/Medicare	$152.77
Rate for Payer: Cash Price	$114.57
Rate for Payer: Cash Price	$67.93
Rate for Payer: Health Smart Auto/Commercial	$90.58
Rate for Payer: Health Smart Auto/Commercial	$152.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$152.77
Rate for Payer: LLUH Dept of Risk Management WC	$140.04
Rate for Payer: LLUH Dept of Risk Management WC	$83.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$113.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$190.96

ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION [10358]

Facility

$150.96

Service Code	CPT Q9968
Hospital Charge Code	1721183
Hospital Revenue Code	636
Min. Negotiated Rate	$83.03
Max. Negotiated Rate	$120.77
Rate for Payer: Cash Price	$67.93
Rate for Payer: Cash Price	$114.57
Rate for Payer: Cigna of CA HMO/PPO	$203.69
Rate for Payer: Cigna of CA HMO/PPO	$120.77
Rate for Payer: Health Smart Auto/Commercial	$90.58
Rate for Payer: Health Smart Auto/Commercial	$152.77
Rate for Payer: LLUH Dept of Risk Management WC	$83.03
Rate for Payer: LLUH Dept of Risk Management WC	$140.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$113.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$190.96

ISOTRETINOIN 10 MG CAPSULE [10359]

Facility

$8.58

Service Code	NDC 61748-301-13
Hospital Charge Code	1710001
Hospital Revenue Code	259
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$6.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.15
Rate for Payer: Aetna of CA Government/Medicare	$5.15
Rate for Payer: Cash Price	$3.86
Rate for Payer: Health Smart Auto/Commercial	$5.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.15
Rate for Payer: LLUH Dept of Risk Management WC	$4.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.44

ISOTRETINOIN 10 MG CAPSULE [10359]

Facility

$6.02

Service Code	NDC 0378-6611-93
Hospital Charge Code	1710001
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.61
Rate for Payer: Aetna of CA Government/Medicare	$3.61
Rate for Payer: Cash Price	$2.71
Rate for Payer: Health Smart Auto/Commercial	$3.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.52

ISOTRETINOIN 10 MG CAPSULE [10359]

Facility

$6.02

Service Code	NDC 0378-6611-93
Hospital Charge Code	1710001
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$2.71
Rate for Payer: Cigna of CA HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.52

ISOTRETINOIN 10 MG CAPSULE [10359]

Facility

$8.58

Service Code	NDC 61748-301-13
Hospital Charge Code	1710001
Hospital Revenue Code	259
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$6.86
Rate for Payer: Cash Price	$3.86
Rate for Payer: Cigna of CA HMO/PPO	$6.86
Rate for Payer: Health Smart Auto/Commercial	$5.15
Rate for Payer: LLUH Dept of Risk Management WC	$4.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.44

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$16.83

Service Code	NDC 0555-1055-56
Hospital Charge Code	1710827
Hospital Revenue Code	259
Min. Negotiated Rate	$9.26
Max. Negotiated Rate	$13.46
Rate for Payer: Cash Price	$7.57
Rate for Payer: Cigna of CA HMO/PPO	$13.46
Rate for Payer: Health Smart Auto/Commercial	$10.10
Rate for Payer: LLUH Dept of Risk Management WC	$9.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.62

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$9.94

Service Code	NDC 61748-302-11
Hospital Charge Code	1710827
Hospital Revenue Code	259
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$7.95
Rate for Payer: Cash Price	$4.47
Rate for Payer: Cigna of CA HMO/PPO	$7.95
Rate for Payer: Health Smart Auto/Commercial	$5.96
Rate for Payer: LLUH Dept of Risk Management WC	$5.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.46

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$9.94

Service Code	NDC 61748-302-11
Hospital Charge Code	1710827
Hospital Revenue Code	259
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$7.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.96
Rate for Payer: Aetna of CA Government/Medicare	$5.96
Rate for Payer: Cash Price	$4.47
Rate for Payer: Health Smart Auto/Commercial	$5.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.96
Rate for Payer: LLUH Dept of Risk Management WC	$5.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.46

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$7.14

Service Code	NDC 0378-6612-93
Hospital Charge Code	1710827
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.28
Rate for Payer: Aetna of CA Government/Medicare	$4.28
Rate for Payer: Cash Price	$3.21
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.36

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$16.83

Service Code	NDC 0555-1055-56
Hospital Charge Code	1710827
Hospital Revenue Code	259
Min. Negotiated Rate	$9.26
Max. Negotiated Rate	$12.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.10
Rate for Payer: Aetna of CA Government/Medicare	$10.10
Rate for Payer: Cash Price	$7.57
Rate for Payer: Health Smart Auto/Commercial	$10.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.10
Rate for Payer: LLUH Dept of Risk Management WC	$9.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.62

ISOTRETINOIN 20 MG CAPSULE [10360]

Facility

$7.14

Service Code	NDC 0378-6612-93
Hospital Charge Code	1710827
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.71
Rate for Payer: Cash Price	$3.21
Rate for Payer: Cigna of CA HMO/PPO	$5.71
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.36

ISOTRETINOIN 40 MG CAPSULE [10361]

Facility

$8.30

Service Code	NDC 0378-6614-93
Hospital Charge Code	1710009
Hospital Revenue Code	259
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$6.64
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cigna of CA HMO/PPO	$6.64
Rate for Payer: Health Smart Auto/Commercial	$4.98
Rate for Payer: LLUH Dept of Risk Management WC	$4.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.22

ISOTRETINOIN 40 MG CAPSULE [10361]

Facility

$8.30

Service Code	NDC 0378-6614-93
Hospital Charge Code	1710009
Hospital Revenue Code	259
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$6.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.98
Rate for Payer: Aetna of CA Government/Medicare	$4.98
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Smart Auto/Commercial	$4.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.98
Rate for Payer: LLUH Dept of Risk Management WC	$4.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.22

ISOTRETINOIN 40 MG CAPSULE [10361]

Facility

$11.84

Service Code	NDC 61748-304-13
Hospital Charge Code	1710009
Hospital Revenue Code	259
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$8.88
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	$5.33
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 Beech St/Commercial/PHCS	$8.88

ISOTRETINOIN 40 MG CAPSULE [10361]

Facility

$11.84

Service Code	NDC 61748-304-13
Hospital Charge Code	1710009
Hospital Revenue Code	259
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$9.47
Rate for Payer: Cash Price	$5.33
Rate for Payer: Cigna of CA HMO/PPO	$9.47
Rate for Payer: Health Smart Auto/Commercial	$7.10
Rate for Payer: LLUH Dept of Risk Management WC	$6.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.88

ISRADIPINE 2.5 MG CAPSULE [10362]

Facility

$1.73

Service Code	NDC 16252-539-01
Hospital Charge Code	1711608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.30

ISRADIPINE 2.5 MG CAPSULE [10362]

Facility

$1.73

Service Code	NDC 16252-539-01
Hospital Charge Code	1711608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.30

ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]

Facility

$0.40

Service Code	NDC 9994-0802-83
Hospital Charge Code	1715228
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.30
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	$0.18
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 Beech St/Commercial/PHCS	$0.30

ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]

Facility

$0.40

Service Code	NDC 9994-0802-83
Hospital Charge Code	1715228
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.30

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$2.00

Service Code	NDC 65162-630-03
Hospital Charge Code	1712171
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$15.10

Service Code	NDC 0378-5100-93
Hospital Charge Code	1712171
Hospital Revenue Code	259
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$12.08
Rate for Payer: Cash Price	$6.80
Rate for Payer: Cigna of CA HMO/PPO	$12.08
Rate for Payer: Health Smart Auto/Commercial	$9.06
Rate for Payer: LLUH Dept of Risk Management WC	$8.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.32

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$15.10

Service Code	NDC 0378-5100-93
Hospital Charge Code	1712171
Hospital Revenue Code	259
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$11.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.06
Rate for Payer: Aetna of CA Government/Medicare	$9.06
Rate for Payer: Cash Price	$6.80
Rate for Payer: Health Smart Auto/Commercial	$9.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.06
Rate for Payer: LLUH Dept of Risk Management WC	$8.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.32

ITRACONAZOLE 100 MG CAPSULE [10364]

Facility

$8.93

Service Code	NDC 10147-1700-7
Hospital Charge Code	1712171
Hospital Revenue Code	259
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$6.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.36
Rate for Payer: Aetna of CA Government/Medicare	$5.36
Rate for Payer: Cash Price	$4.02
Rate for Payer: Health Smart Auto/Commercial	$5.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.36
Rate for Payer: LLUH Dept of Risk Management WC	$4.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.70

Know your out-of-pocket cost for care.

All Charges