Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.22

Service Code	NDC 68084-318-11
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
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	$0.10
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	$0.17

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.07

Service Code	NDC 51672-4130-1
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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: 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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.07

Service Code	NDC 13668-045-01
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.07

Service Code	NDC 29300-111-01
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.07

Service Code	NDC 29300-111-01
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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: 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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.07

Service Code	NDC 51672-4130-1
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$6.36

Service Code	NDC 27241-184-30
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.86
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.77

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$9.13

Service Code	NDC 49884-485-54
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.48
Rate for Payer: Aetna of CA Government/Medicare	$5.48
Rate for Payer: Cash Price	$4.11
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.85

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$6.36

Service Code	NDC 27241-184-30
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.09
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cigna of CA HMO/PPO	$5.09
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.77

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$9.13

Service Code	NDC 49884-485-11
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$7.30
Rate for Payer: Cash Price	$4.11
Rate for Payer: Cigna of CA HMO/PPO	$7.30
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.85

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$9.13

Service Code	NDC 49884-485-54
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$7.30
Rate for Payer: Cash Price	$4.11
Rate for Payer: Cigna of CA HMO/PPO	$7.30
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.85

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$9.13

Service Code	NDC 49884-485-11
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.48
Rate for Payer: Aetna of CA Government/Medicare	$5.48
Rate for Payer: Cash Price	$4.11
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.85

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$9.13

Service Code	NDC 0115-9940-68
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.48
Rate for Payer: Aetna of CA Government/Medicare	$5.48
Rate for Payer: Cash Price	$4.11
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.85

LAMOTRIGINE 50 MG DISINTEGRATING TABLET [96940]

Facility

$9.13

Service Code	NDC 0115-9940-68
Hospital Charge Code	1712435
Hospital Revenue Code	259
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$7.30
Rate for Payer: Cash Price	$4.11
Rate for Payer: Cigna of CA HMO/PPO	$7.30
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.85

LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]

Facility

$18.48

Service Code	NDC 0173-0526-00
Hospital Charge Code	1711792
Hospital Revenue Code	259
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$13.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.09
Rate for Payer: Aetna of CA Government/Medicare	$11.09
Rate for Payer: Cash Price	$8.32
Rate for Payer: Health Smart Auto/Commercial	$11.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.09
Rate for Payer: LLUH Dept of Risk Management WC	$10.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.86

LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET [104568]

Facility

$18.48

Service Code	NDC 0173-0526-00
Hospital Charge Code	1711792
Hospital Revenue Code	259
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$14.78
Rate for Payer: Cash Price	$8.32
Rate for Payer: Cigna of CA HMO/PPO	$14.78
Rate for Payer: Health Smart Auto/Commercial	$11.09
Rate for Payer: LLUH Dept of Risk Management WC	$10.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.86

LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]

Facility

$0.07

Service Code	NDC 7214000022
Hospital Charge Code	NDG11371C
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]

Facility

$0.09

Service Code	NDC 7214003868
Hospital Charge Code	NDG11371B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]

Facility

$0.09

Service Code	NDC 7214003868
Hospital Charge Code	NDG11371B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM [120012]

Facility

$0.07

Service Code	NDC 7214000022
Hospital Charge Code	NDG11371C
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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: 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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LANOLIN-MINERAL OIL LOTION [2787]

Facility

$0.03

Service Code	NDC 7214011019
Hospital Charge Code	NDG2787
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
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	$0.02

LANOLIN-MINERAL OIL LOTION [2787]

Facility

$0.03

Service Code	NDC 7214011019
Hospital Charge Code	NDG2787
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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	$0.02

LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE [88570]

Facility

$36,528.00

Service Code	CPT J1930
Hospital Charge Code	ERX88570
Hospital Revenue Code	636
Min. Negotiated Rate	$20,090.40
Max. Negotiated Rate	$27,396.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21,916.80
Rate for Payer: Aetna of CA Government/Medicare	$21,916.80
Rate for Payer: Cash Price	$16,437.60
Rate for Payer: Health Smart Auto/Commercial	$21,916.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21,916.80
Rate for Payer: LLUH Dept of Risk Management WC	$20,090.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27,396.00

LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE [88570]

Facility

$36,528.00

Service Code	CPT J1930
Hospital Charge Code	ERX88570
Hospital Revenue Code	636
Min. Negotiated Rate	$20,090.40
Max. Negotiated Rate	$29,222.40
Rate for Payer: Cash Price	$16,437.60
Rate for Payer: Cigna of CA HMO/PPO	$29,222.40
Rate for Payer: Health Smart Auto/Commercial	$21,916.80
Rate for Payer: LLUH Dept of Risk Management WC	$20,090.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27,396.00

LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE [87860]

Facility

$32,432.00

Service Code	CPT J1930
Hospital Charge Code	NDG87860
Hospital Revenue Code	636
Min. Negotiated Rate	$17,837.60
Max. Negotiated Rate	$25,945.60
Rate for Payer: Cash Price	$14,594.40
Rate for Payer: Cigna of CA HMO/PPO	$25,945.60
Rate for Payer: Health Smart Auto/Commercial	$19,459.20
Rate for Payer: LLUH Dept of Risk Management WC	$17,837.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24,324.00

Know your out-of-pocket cost for care.

All Charges