Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.29

Service Code	NDC 0904-7276-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.45

Service Code	NDC 0121-0868-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.46

Service Code	NDC 60687-800-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.29

Service Code	NDC 0904-7276-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.46

Service Code	NDC 60687-800-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.29

Service Code	NDC 0904-7276-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.46

Service Code	NDC 60687-800-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.29

Service Code	NDC 0904-7276-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.45

Service Code	NDC 0121-0868-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.47

Service Code	NDC 0121-0868-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.23

Service Code	NDC 0121-1045-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$0.22

Service Code	NDC 9999-0537-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.68

Service Code	NDC 51672-1263-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.68

Service Code	NDC 51672-1263-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]

Facility

$270.01

Service Code	HCPCS J9301
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$148.51
Max. Negotiated Rate	$216.01
Rate for Payer: Cash Price	$148.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$216.01
Rate for Payer: Health Smart Auto/Commercial	$162.01
Rate for Payer: LLUH Dept of Risk Management WC	$148.51
Rate for Payer: Multiplan Commercial	$202.51

OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]

Facility

$270.01

Service Code	HCPCS J9301
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$148.51
Max. Negotiated Rate	$216.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$162.01
Rate for Payer: Aetna of CA Government/Medicare	$162.01
Rate for Payer: Cash Price	$148.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$216.01
Rate for Payer: Health Smart Auto/Commercial	$162.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$162.01
Rate for Payer: LLUH Dept of Risk Management WC	$148.51
Rate for Payer: Multiplan Commercial	$202.51

OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]

Facility

$119.25

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$95.40
Rate for Payer: Cash Price	$65.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.40
Rate for Payer: Health Smart Auto/Commercial	$71.55
Rate for Payer: LLUH Dept of Risk Management WC	$65.59
Rate for Payer: Multiplan Commercial	$89.44

OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]

Facility

$119.25

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.55
Rate for Payer: Aetna of CA Government/Medicare	$71.55
Rate for Payer: Cash Price	$65.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.40
Rate for Payer: Health Smart Auto/Commercial	$71.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.55
Rate for Payer: LLUH Dept of Risk Management WC	$65.59
Rate for Payer: Multiplan Commercial	$89.44

OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]

Facility

$3.90

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$3.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.68
Rate for Payer: Aetna of CA Government/Medicare	$7.16
Rate for Payer: Aetna of CA Government/Medicare	$2.34
Rate for Payer: Aetna of CA Government/Medicare	$4.68
Rate for Payer: Cash Price	$4.29
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cash Price	$6.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.12
Rate for Payer: Health Smart Auto/Commercial	$7.16
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: LLUH Dept of Risk Management WC	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$6.56
Rate for Payer: Multiplan Commercial	$2.92
Rate for Payer: Multiplan Commercial	$5.85
Rate for Payer: Multiplan Commercial	$8.95

OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]

Facility

$3.90

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cash Price	$6.56
Rate for Payer: Cash Price	$4.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.12
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: Health Smart Auto/Commercial	$7.16
Rate for Payer: LLUH Dept of Risk Management WC	$6.56
Rate for Payer: LLUH Dept of Risk Management WC	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Commercial	$2.92
Rate for Payer: Multiplan Commercial	$8.95
Rate for Payer: Multiplan Commercial	$5.85

OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]

Facility

$59.63

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$47.70
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$12.87
Rate for Payer: Cash Price	$23.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.70
Rate for Payer: Health Smart Auto/Commercial	$35.78
Rate for Payer: Health Smart Auto/Commercial	$14.04
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.87
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$32.80
Rate for Payer: Multiplan Commercial	$31.50
Rate for Payer: Multiplan Commercial	$17.55
Rate for Payer: Multiplan Commercial	$44.72

OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]

Facility

$59.63

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.04
Rate for Payer: Aetna of CA Government/Medicare	$35.78
Rate for Payer: Aetna of CA Government/Medicare	$14.04
Rate for Payer: Aetna of CA Government/Medicare	$25.20
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$23.10
Rate for Payer: Cash Price	$12.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.72
Rate for Payer: Health Smart Auto/Commercial	$35.78
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: Health Smart Auto/Commercial	$14.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.78
Rate for Payer: LLUH Dept of Risk Management WC	$12.87
Rate for Payer: LLUH Dept of Risk Management WC	$32.80
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: Multiplan Commercial	$31.50
Rate for Payer: Multiplan Commercial	$17.55
Rate for Payer: Multiplan Commercial	$44.72

OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]

Facility

$3.48

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cash Price	$2.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.32
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Commercial	$2.61
Rate for Payer: Multiplan Commercial	$4.05

OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]

Facility

$5.40

Service Code	HCPCS J2354
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$4.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.09
Rate for Payer: Aetna of CA Government/Medicare	$3.24
Rate for Payer: Aetna of CA Government/Medicare	$2.09
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cash Price	$2.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.32
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Commercial	$2.61
Rate for Payer: Multiplan Commercial	$4.05

OFLOXACIN 0.3 % EAR DROPS [22257]

Facility

$3.60

Service Code	NDC 70756-609-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

Know your out-of-pocket cost for care.

All Charges