Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LEFLUNOMIDE 10 MG TABLET [23872]

Facility

$3.20

Service Code	NDC 60505-2502-1
Hospital Charge Code	1712456
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cigna of CA HMO/PPO	$2.56
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.40

LEFLUNOMIDE 10 MG TABLET [23872]

Facility

$1.31

Service Code	NDC 70710-1157-3
Hospital Charge Code	1712456
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

LEFLUNOMIDE 10 MG TABLET [23872]

Facility

$1.31

Service Code	NDC 70710-1157-3
Hospital Charge Code	1712456
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

LEFLUNOMIDE 10 MG TABLET [23872]

Facility

$3.20

Service Code	NDC 60505-2502-1
Hospital Charge Code	1712456
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.92
Rate for Payer: Aetna of CA Government/Medicare	$1.92
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.40

LEFLUNOMIDE 20 MG TABLET [23873]

Facility

$0.88

Service Code	NDC 23155-044-03
Hospital Charge Code	1710881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.66

LEFLUNOMIDE 20 MG TABLET [23873]

Facility

$0.88

Service Code	NDC 23155-044-03
Hospital Charge Code	1710881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.66

LEFLUNOMIDE 20 MG TABLET [23873]

Facility

$6.00

Service Code	NDC 62332-062-30
Hospital Charge Code	1710881
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

LEFLUNOMIDE 20 MG TABLET [23873]

Facility

$3.32

Service Code	NDC 60505-2503-1
Hospital Charge Code	1710881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.99
Rate for Payer: Aetna of CA Government/Medicare	$1.99
Rate for Payer: Cash Price	$1.49
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.49

LEFLUNOMIDE 20 MG TABLET [23873]

Facility

$3.32

Service Code	NDC 60505-2503-1
Hospital Charge Code	1710881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.49
Rate for Payer: Cigna of CA HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.49

LEFLUNOMIDE 20 MG TABLET [23873]

Facility

$6.00

Service Code	NDC 62332-062-30
Hospital Charge Code	1710881
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]

Facility

$17.22

Service Code	NDC 0006-5004-01
Hospital Charge Code	NDG220341
Hospital Revenue Code	250
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$13.78
Rate for Payer: Cash Price	$7.75
Rate for Payer: Cigna of CA HMO/PPO	$13.78
Rate for Payer: Health Smart Auto/Commercial	$10.33
Rate for Payer: LLUH Dept of Risk Management WC	$9.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.92

LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]

Facility

$17.22

Service Code	NDC 0006-5004-02
Hospital Charge Code	NDG220341
Hospital Revenue Code	250
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$13.78
Rate for Payer: Cash Price	$7.75
Rate for Payer: Cigna of CA HMO/PPO	$13.78
Rate for Payer: Health Smart Auto/Commercial	$10.33
Rate for Payer: LLUH Dept of Risk Management WC	$9.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.92

LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]

Facility

$17.22

Service Code	NDC 0006-5004-02
Hospital Charge Code	NDG220341
Hospital Revenue Code	250
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$12.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.33
Rate for Payer: Aetna of CA Government/Medicare	$10.33
Rate for Payer: Cash Price	$7.75
Rate for Payer: Health Smart Auto/Commercial	$10.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.33
Rate for Payer: LLUH Dept of Risk Management WC	$9.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.92

LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION [220341]

Facility

$17.22

Service Code	NDC 0006-5004-01
Hospital Charge Code	NDG220341
Hospital Revenue Code	250
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$12.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.33
Rate for Payer: Aetna of CA Government/Medicare	$10.33
Rate for Payer: Cash Price	$7.75
Rate for Payer: Health Smart Auto/Commercial	$10.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.33
Rate for Payer: LLUH Dept of Risk Management WC	$9.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.92

LETROZOLE 2.5 MG TABLET [21509]

Facility

$0.67

Service Code	NDC 50268-476-11
Hospital Charge Code	1710976
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

LETROZOLE 2.5 MG TABLET [21509]

Facility

$0.36

Service Code	NDC 16729-034-10
Hospital Charge Code	1710976
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

LETROZOLE 2.5 MG TABLET [21509]

Facility

$0.67

Service Code	NDC 50268-476-15
Hospital Charge Code	1710976
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

LETROZOLE 2.5 MG TABLET [21509]

Facility

$0.67

Service Code	NDC 50268-476-11
Hospital Charge Code	1710976
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

LETROZOLE 2.5 MG TABLET [21509]

Facility

$0.67

Service Code	NDC 50268-476-15
Hospital Charge Code	1710976
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

LETROZOLE 2.5 MG TABLET [21509]

Facility

$0.36

Service Code	NDC 16729-034-10
Hospital Charge Code	1710976
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]

Facility

$4.80

Service Code	NDC 5060054920
Hospital Charge Code	ERX78240
Hospital Revenue Code	259
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$2.16
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

LEUCINE 0.1 GRAM-15 KCAL/4 GRAM ORAL POWDER PACKET [78240]

Facility

$4.80

Service Code	NDC 5060054920
Hospital Charge Code	ERX78240
Hospital Revenue Code	259
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cigna of CA HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]

Facility

$19.20

Service Code	CPT J0640
Hospital Charge Code	1720108
Hospital Revenue Code	636
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$11.52
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$8.64
Rate for Payer: Health Smart Auto/Commercial	$11.52
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$10.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]

Facility

$19.20

Service Code	CPT J0640
Hospital Charge Code	1720108
Hospital Revenue Code	636
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$15.36
Rate for Payer: Cash Price	$8.64
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Cigna of CA HMO/PPO	$15.36
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Health Smart Auto/Commercial	$11.52
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$10.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]

Facility

$2.84

Service Code	CPT J0640
Hospital Charge Code	NDG15370A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Cash Price	$1.28
Rate for Payer: Cigna of CA HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.13

Know your out-of-pocket cost for care.

All Charges