Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NALTREXONE 50 MG TABLET [10685]

Facility

$1.80

Service Code	NDC 47335-326-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.35

NALTREXONE 50 MG TABLET [10685]

Facility

$2.32

Service Code	NDC 0406-1170-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Commercial	$1.74

NALTREXONE 50 MG TABLET [10685]

Facility

$2.18

Service Code	NDC 16729-081-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.74
Rate for Payer: Cash Price	$1.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.74
Rate for Payer: Health Smart Auto/Commercial	$1.31
Rate for Payer: LLUH Dept of Risk Management WC	$1.20
Rate for Payer: Multiplan Commercial	$1.64

NALTREXONE 50 MG TABLET [10685]

Facility

$2.18

Service Code	NDC 16729-081-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.31
Rate for Payer: Aetna of CA Government/Medicare	$1.31
Rate for Payer: Cash Price	$1.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.74
Rate for Payer: Health Smart Auto/Commercial	$1.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.31
Rate for Payer: LLUH Dept of Risk Management WC	$1.20
Rate for Payer: Multiplan Commercial	$1.64

NALTREXONE 50 MG TABLET [10685]

Facility

$2.32

Service Code	NDC 0406-1170-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.39
Rate for Payer: Aetna of CA Government/Medicare	$1.39
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Commercial	$1.74

NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS [5384]

Facility

$0.63

Service Code	NDC 0065-0085-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
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	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

NAPHAZOLINE 0.025 %-PHENIRAMINE 0.3 % EYE DROPS [5384]

Facility

$0.63

Service Code	NDC 0065-0085-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
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	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

NAPROXEN 250 MG TABLET [5391]

Facility

$0.31

Service Code	NDC 50268-594-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
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	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
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	$0.17
Rate for Payer: Multiplan Commercial	$0.23

NAPROXEN 250 MG TABLET [5391]

Facility

$0.10

Service Code	NDC 68462-188-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
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: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

NAPROXEN 250 MG TABLET [5391]

Facility

$0.31

Service Code	NDC 50268-594-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
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	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
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	$0.17
Rate for Payer: Multiplan Commercial	$0.23

NAPROXEN 250 MG TABLET [5391]

Facility

$0.31

Service Code	NDC 50268-594-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

NAPROXEN 250 MG TABLET [5391]

Facility

$0.10

Service Code	NDC 68462-188-01
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	$0.06
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

NAPROXEN 250 MG TABLET [5391]

Facility

$0.31

Service Code	NDC 50268-594-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

NAPROXEN 375 MG TABLET [5392]

Facility

$0.12

Service Code	NDC 68462-189-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

NAPROXEN 375 MG TABLET [5392]

Facility

$0.12

Service Code	NDC 68462-189-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

NAPROXEN 500 MG TABLET [5393]

Facility

$0.14

Service Code	NDC 68462-190-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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	$0.08
Rate for Payer: Multiplan Commercial	$0.11

NAPROXEN 500 MG TABLET [5393]

Facility

$0.14

Service Code	NDC 68462-190-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

NAPROXEN 500 MG TABLET [5393]

Facility

$0.14

Service Code	NDC 65162-190-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

NAPROXEN 500 MG TABLET [5393]

Facility

$0.14

Service Code	NDC 65162-190-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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	$0.08
Rate for Payer: Multiplan Commercial	$0.11

NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION [40120]

Facility

$710.34

Service Code	HCPCS J2323
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$390.69
Max. Negotiated Rate	$568.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$426.20
Rate for Payer: Aetna of CA Government/Medicare	$426.20
Rate for Payer: Cash Price	$390.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$568.27
Rate for Payer: Health Smart Auto/Commercial	$426.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$426.20
Rate for Payer: LLUH Dept of Risk Management WC	$390.69
Rate for Payer: Multiplan Commercial	$532.75

NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION [40120]

Facility

$710.34

Service Code	HCPCS J2323
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$390.69
Max. Negotiated Rate	$568.27
Rate for Payer: Cash Price	$390.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$568.27
Rate for Payer: Health Smart Auto/Commercial	$426.20
Rate for Payer: LLUH Dept of Risk Management WC	$390.69
Rate for Payer: Multiplan Commercial	$532.75

NEBIVOLOL 10 MG TABLET [89286]

Facility

$0.28

Service Code	NDC 43547-526-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

NEBIVOLOL 10 MG TABLET [89286]

Facility

$4.20

Service Code	NDC 60687-652-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

NEBIVOLOL 10 MG TABLET [89286]

Facility

$4.20

Service Code	NDC 60687-652-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

NEBIVOLOL 10 MG TABLET [89286]

Facility

$0.56

Service Code	NDC 67877-391-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

Know your out-of-pocket cost for care.

All Charges