Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OLOPATADINE 0.1 % EYE DROPS [19452]

Facility

$1.81

Service Code	NDC 46122-672-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.45
Rate for Payer: Cash Price	$1.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.45
Rate for Payer: Health Smart Auto/Commercial	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.00
Rate for Payer: Multiplan Commercial	$1.36

OLUTASIDENIB 150 MG CAPSULE [236323]

Facility

$683.20

Service Code	NDC 71332-005-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$375.76
Max. Negotiated Rate	$546.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$409.92
Rate for Payer: Aetna of CA Government/Medicare	$409.92
Rate for Payer: Cash Price	$375.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$546.56
Rate for Payer: Health Smart Auto/Commercial	$409.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$409.92
Rate for Payer: LLUH Dept of Risk Management WC	$375.76
Rate for Payer: Multiplan Commercial	$512.40

OLUTASIDENIB 150 MG CAPSULE [236323]

Facility

$683.20

Service Code	NDC 71332-005-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$375.76
Max. Negotiated Rate	$546.56
Rate for Payer: Cash Price	$375.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$546.56
Rate for Payer: Health Smart Auto/Commercial	$409.92
Rate for Payer: LLUH Dept of Risk Management WC	$375.76
Rate for Payer: Multiplan Commercial	$512.40

OMEGA-3 300 MG-DHA 120 MG-EPA 180 MG-FISH OIL 1,000 MG CAPSULE [231730]

Facility

$0.06

Service Code	NDC 0904723860
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

OMEGA-3 300 MG-DHA 120 MG-EPA 180 MG-FISH OIL 1,000 MG CAPSULE [231730]

Facility

$0.06

Service Code	NDC 0904723860
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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	$0.03
Rate for Payer: Multiplan Commercial	$0.05

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.92
Rate for Payer: Cash Price	$2.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Commercial	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.27

Service Code	NDC 64380-761-11
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	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.27

Service Code	NDC 64380-761-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
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	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.30

Service Code	NDC 70756-423-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.19
Rate for Payer: Aetna of CA Government/Medicare	$2.19
Rate for Payer: Cash Price	$2.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Commercial	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.92
Rate for Payer: Cash Price	$2.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Commercial	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.45

Service Code	NDC 31722-936-12
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

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.97

Service Code	NDC 60505-3170-7
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.73

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.19
Rate for Payer: Aetna of CA Government/Medicare	$2.19
Rate for Payer: Cash Price	$2.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Commercial	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.30

Service Code	NDC 70756-423-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.45

Service Code	NDC 31722-936-12
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

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.97

Service Code	NDC 60505-3170-7
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.73

OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]

Facility

$0.08

Service Code	NDC 1191710202
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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	$0.04
Rate for Payer: Multiplan Commercial	$0.06

OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]

Facility

$0.08

Service Code	NDC 1191710202
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]

Facility

$0.86

Service Code	NDC 37000-459-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]

Facility

$0.86

Service Code	NDC 37000-459-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]

Facility

$781.20

Service Code	HCPCS J0585
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$429.66
Max. Negotiated Rate	$624.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$468.72
Rate for Payer: Aetna of CA Government/Medicare	$468.72
Rate for Payer: Cash Price	$429.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$624.96
Rate for Payer: Health Smart Auto/Commercial	$468.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$468.72
Rate for Payer: LLUH Dept of Risk Management WC	$429.66
Rate for Payer: Multiplan Commercial	$585.90

ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]

Facility

$781.20

Service Code	HCPCS J0585
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$429.66
Max. Negotiated Rate	$624.96
Rate for Payer: Cash Price	$429.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$624.96
Rate for Payer: Health Smart Auto/Commercial	$468.72
Rate for Payer: LLUH Dept of Risk Management WC	$429.66
Rate for Payer: Multiplan Commercial	$585.90

ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]

Facility

$434.40

Service Code	NDC 0023-3919-50
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$238.92
Max. Negotiated Rate	$347.52
Rate for Payer: Cash Price	$238.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.52
Rate for Payer: Health Smart Auto/Commercial	$260.64
Rate for Payer: LLUH Dept of Risk Management WC	$238.92
Rate for Payer: Multiplan Commercial	$325.80

ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]

Facility

$434.40

Service Code	NDC 0023-3919-50
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$238.92
Max. Negotiated Rate	$347.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$260.64
Rate for Payer: Aetna of CA Government/Medicare	$260.64
Rate for Payer: Cash Price	$238.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.52
Rate for Payer: Health Smart Auto/Commercial	$260.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$260.64
Rate for Payer: LLUH Dept of Risk Management WC	$238.92
Rate for Payer: Multiplan Commercial	$325.80

Know your out-of-pocket cost for care.

All Charges