Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LABETALOL 5 MG/ML INTRAVENOUS SOLUTION WRAP [40820329]

Facility

$0.13

Service Code	CPT J1920
Hospital Charge Code	NDC10372
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

LABETALOL 5 MG/ML INTRAVENOUS SOLUTION WRAP [40820329]

Facility

$0.42

Service Code	CPT J1920
Hospital Charge Code	NDG188812
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

LABETALOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080288]

Facility

$0.04

Service Code	NDC 9994-0802-88
Hospital Charge Code	1715066
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: 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 Beech St/Commercial/PHCS	$0.03

LABETALOL ORAL SUSPENSION COMPOUND 10 MG/ML [4080288]

Facility

$0.04

Service Code	NDC 9994-0802-88
Hospital Charge Code	1715066
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

L.ACIDOPHILUS-L.BULGAR-B.BIFID-S.THERMOPH 1 BILLION CELL-250 MG TABLET [120891]

Facility

$0.32

Service Code	NDC 6373610506
Hospital Charge Code	1711241
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

L.ACIDOPHILUS-L.BULGAR-B.BIFID-S.THERMOPH 1 BILLION CELL-250 MG TABLET [120891]

Facility

$0.32

Service Code	NDC 6373610506
Hospital Charge Code	1711241
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

L.ACIDOPHILUS-L.BULGAR-B.BIFID-S.THERMOPH 1 BILLION CELL-250 MG TABLET [120891]

Facility

$0.35

Service Code	NDC 6373610504
Hospital Charge Code	1711241
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

L.ACIDOPHILUS-L.BULGAR-B.BIFID-S.THERMOPH 1 BILLION CELL-250 MG TABLET [120891]

Facility

$0.35

Service Code	NDC 6373610504
Hospital Charge Code	1711241
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

LACOSAMIDE 100 MG TABLET [96969]

Facility

$2.46

Service Code	NDC 0904-7245-68
Hospital Charge Code	1730179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

LACOSAMIDE 100 MG TABLET [96969]

Facility

$2.46

Service Code	NDC 0904-7245-68
Hospital Charge Code	1730179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.97
Rate for Payer: Cash Price	$1.11
Rate for Payer: Cigna of CA HMO/PPO	$1.97
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]

Facility

$0.67

Service Code	NDC 31722-627-26
Hospital Charge Code	NDG105482
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.50

LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]

Facility

$0.21

Service Code	NDC 67877-732-95
Hospital Charge Code	NDG105482
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]

Facility

$0.21

Service Code	NDC 67877-732-95
Hospital Charge Code	NDG105482
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

LACOSAMIDE 10 MG/ML ORAL SOLUTION [105482]

Facility

$0.67

Service Code	NDC 31722-627-26
Hospital Charge Code	NDG105482
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.50
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	$0.30
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 Beech St/Commercial/PHCS	$0.50

LACOSAMIDE 150 MG TABLET [96970]

Facility

$0.86

Service Code	NDC 31722-814-60
Hospital Charge Code	1730180
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

LACOSAMIDE 150 MG TABLET [96970]

Facility

$0.86

Service Code	NDC 31722-814-60
Hospital Charge Code	1730180
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION [96972]

Facility

$3.93

Service Code	CPT C9254
Hospital Charge Code	1730170
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$3.14
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.87
Rate for Payer: Cigna of CA HMO/PPO	$3.14
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION [96972]

Facility

$3.93

Service Code	CPT C9254
Hospital Charge Code	1730170
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$2.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$2.36
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.95

LACOSAMIDE 200 MG TABLET [96971]

Facility

$3.90

Service Code	NDC 60687-698-11
Hospital Charge Code	1730181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of CA HMO/PPO	$3.12
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.92

LACOSAMIDE 200 MG TABLET [96971]

Facility

$3.90

Service Code	NDC 60687-698-57
Hospital Charge Code	1730181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of CA HMO/PPO	$3.12
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.92

LACOSAMIDE 200 MG TABLET [96971]

Facility

$3.90

Service Code	NDC 60687-698-11
Hospital Charge Code	1730181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.34
Rate for Payer: Aetna of CA Government/Medicare	$2.34
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.92

LACOSAMIDE 200 MG TABLET [96971]

Facility

$3.90

Service Code	NDC 60687-698-57
Hospital Charge Code	1730181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.34
Rate for Payer: Aetna of CA Government/Medicare	$2.34
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.92

LACOSAMIDE 50 MG TABLET [96968]

Facility

$2.36

Service Code	NDC 60687-676-57
Hospital Charge Code	1730178
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.42
Rate for Payer: Aetna of CA Government/Medicare	$1.42
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.77

LACOSAMIDE 50 MG TABLET [96968]

Facility

$2.36

Service Code	NDC 60687-676-11
Hospital Charge Code	1730178
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.77
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: Cash Price	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.42
Rate for Payer: Aetna of CA Government/Medicare	$1.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.77

LACOSAMIDE 50 MG TABLET [96968]

Facility

$2.36

Service Code	NDC 60687-676-57
Hospital Charge Code	1730178
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.89
Rate for Payer: Cash Price	$1.06
Rate for Payer: Cigna of CA HMO/PPO	$1.89
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.77

Know your out-of-pocket cost for care.

All Charges