Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]

Facility

$0.21

Service Code	HCPCS J2280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.16
Rate for Payer: Multiplan Commercial	$0.18

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$7.00

Service Code	NDC 57237-156-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$3.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Commercial	$5.25

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 50268-576-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.85
Rate for Payer: Aetna of CA Government/Medicare	$4.85
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$7.00

Service Code	NDC 57237-156-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.20
Rate for Payer: Aetna of CA Government/Medicare	$4.20
Rate for Payer: Cash Price	$3.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Commercial	$5.25

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 50268-576-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 50268-576-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 50268-576-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.85
Rate for Payer: Aetna of CA Government/Medicare	$4.85
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]

Facility

$26.25

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.75
Rate for Payer: Aetna of CA Government/Medicare	$15.75
Rate for Payer: Cash Price	$14.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.00
Rate for Payer: Health Smart Auto/Commercial	$15.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.75
Rate for Payer: LLUH Dept of Risk Management WC	$14.44
Rate for Payer: Multiplan Commercial	$19.69

MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]

Facility

$26.25

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$21.00
Rate for Payer: Cash Price	$14.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.00
Rate for Payer: Health Smart Auto/Commercial	$15.75
Rate for Payer: LLUH Dept of Risk Management WC	$14.44
Rate for Payer: Multiplan Commercial	$19.69

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.01

Service Code	NDC 9408-0306-02
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

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.01

Service Code	NDC 9408-0306-02
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

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.01

Service Code	NDC 9408-0306-01
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

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.01

Service Code	NDC 9408-0306-01
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

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.04

Service Code	NDC 9994-0803-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.62

Service Code	NDC 9994-0803-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
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

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.04

Service Code	NDC 9994-0803-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.62

Service Code	NDC 9994-0803-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
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

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.06

Service Code	NDC 8770143233
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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	$0.03
Rate for Payer: Multiplan Commercial	$0.05

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.26

Service Code	NDC 7733386110
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
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 Commercial	$0.20

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.05

Service Code	NDC 4098522368
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.26

Service Code	NDC 7733386125
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
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 Commercial	$0.20

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.06

Service Code	NDC 8770143233
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.26

Service Code	NDC 7733386110
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.05

Service Code	NDC 4098522368
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.26

Service Code	NDC 7733386125
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

Know your out-of-pocket cost for care.

All Charges