Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$0.12

Service Code	NDC 68462-639-25
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

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$1.02

Service Code	NDC 43598-436-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$1.02

Service Code	NDC 43598-436-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$1.02

Service Code	NDC 43598-436-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH [27475]

Facility

$1.13

Service Code	NDC 49730-113-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.85

NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH [27475]

Facility

$1.13

Service Code	NDC 49730-113-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.85

NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [14895]

Facility

$0.12

Service Code	HCPCS J2305
Hospital Charge Code	901700025
Hospital Revenue Code	636
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	$0.06
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

NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [14895]

Facility

$0.12

Service Code	HCPCS J2305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
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

NITROGLYCERIN 10 MG/50 ML D5.2NS SYRINGE [4080694]

Facility

$0.88

Service Code	NDC 9994-0806-94
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.66

NITROGLYCERIN 10 MG/50 ML D5.2NS SYRINGE [4080694]

Facility

$0.88

Service Code	NDC 9994-0806-94
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
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	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
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 Commercial	$0.66

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]

Facility

$2.91

Service Code	NDC 0281-0326-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.75
Rate for Payer: Aetna of CA Government/Medicare	$1.75
Rate for Payer: Cash Price	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.33
Rate for Payer: Health Smart Auto/Commercial	$1.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.75
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Commercial	$2.18

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]

Facility

$2.91

Service Code	NDC 0281-0326-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.33
Rate for Payer: Cash Price	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.33
Rate for Payer: Health Smart Auto/Commercial	$1.75
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Commercial	$2.18

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT BULK TUBE [4081590]

Facility

$1.50

Service Code	NDC 0281-0326-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT BULK TUBE [4081590]

Facility

$1.50

Service Code	NDC 0281-0326-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT PERIPHERAL ISCHEMIA [4085606]

Facility

$2.91

Service Code	NDC 0281-0326-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.75
Rate for Payer: Aetna of CA Government/Medicare	$1.75
Rate for Payer: Cash Price	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.33
Rate for Payer: Health Smart Auto/Commercial	$1.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.75
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Commercial	$2.18

NITROGLYCERIN 2 % TRANSDERMAL OINTMENT PERIPHERAL ISCHEMIA [4085606]

Facility

$2.91

Service Code	NDC 0281-0326-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.33
Rate for Payer: Cash Price	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.33
Rate for Payer: Health Smart Auto/Commercial	$1.75
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Commercial	$2.18

NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL AEROSOL [103879]

Facility

$88.42

Service Code	NDC 76299-430-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$48.63
Max. Negotiated Rate	$70.74
Rate for Payer: Cash Price	$48.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$70.74
Rate for Payer: Health Smart Auto/Commercial	$53.05
Rate for Payer: LLUH Dept of Risk Management WC	$48.63
Rate for Payer: Multiplan Commercial	$66.31

NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL AEROSOL [103879]

Facility

$88.42

Service Code	NDC 76299-430-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$48.63
Max. Negotiated Rate	$70.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.05
Rate for Payer: Aetna of CA Government/Medicare	$53.05
Rate for Payer: Cash Price	$48.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$70.74
Rate for Payer: Health Smart Auto/Commercial	$53.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.05
Rate for Payer: LLUH Dept of Risk Management WC	$48.63
Rate for Payer: Multiplan Commercial	$66.31

NITROGLYCERIN 40 MCG/ML BOLUS FOR ANESTHESIA [4080670]

Facility

$0.17

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

NITROGLYCERIN 40 MCG/ML BOLUS FOR ANESTHESIA [4080670]

Facility

$0.17

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [5599]

Facility

$1.87

Service Code	HCPCS J2305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.12
Rate for Payer: Aetna of CA Government/Medicare	$1.12
Rate for Payer: Cash Price	$1.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.50
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Commercial	$1.40

NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [5599]

Facility

$1.87

Service Code	HCPCS J2305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.50
Rate for Payer: Cash Price	$1.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.50
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Commercial	$1.40

NITROGLYCERIN 5 MG/50 ML D5.2NS SYRINGE [4080695]

Facility

$0.88

Service Code	NDC 9994-0806-95
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
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	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
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 Commercial	$0.66

NITROGLYCERIN 5 MG/50 ML D5.2NS SYRINGE [4080695]

Facility

$0.88

Service Code	NDC 9994-0806-95
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.66

NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION [208460]

Facility

$397.15

Service Code	HCPCS J9299
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$218.43
Max. Negotiated Rate	$317.72
Rate for Payer: Cash Price	$218.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$317.72
Rate for Payer: Health Smart Auto/Commercial	$238.29
Rate for Payer: LLUH Dept of Risk Management WC	$218.43
Rate for Payer: Multiplan Commercial	$297.86

Know your out-of-pocket cost for care.

All Charges