Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION [32855]

Facility

$11.23

Service Code	HCPCS J2430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$6.17
Rate for Payer: Cash Price	$6.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: Health Smart Auto/Commercial	$7.60
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: LLUH Dept of Risk Management WC	$6.97
Rate for Payer: Multiplan Commercial	$8.42
Rate for Payer: Multiplan Commercial	$9.50

PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION [108055]

Facility

$434.80

Service Code	HCPCS J9303
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$239.14
Max. Negotiated Rate	$347.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$260.88
Rate for Payer: Aetna of CA Government/Medicare	$260.88
Rate for Payer: Cash Price	$239.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.84
Rate for Payer: Health Smart Auto/Commercial	$260.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$260.88
Rate for Payer: LLUH Dept of Risk Management WC	$239.14
Rate for Payer: Multiplan Commercial	$326.10

PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION [108055]

Facility

$434.80

Service Code	HCPCS J9303
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$239.14
Max. Negotiated Rate	$347.84
Rate for Payer: Cash Price	$239.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.84
Rate for Payer: Health Smart Auto/Commercial	$260.88
Rate for Payer: LLUH Dept of Risk Management WC	$239.14
Rate for Payer: Multiplan Commercial	$326.10

PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [108057]

Facility

$434.80

Service Code	HCPCS J9303
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$239.14
Max. Negotiated Rate	$347.84
Rate for Payer: Cash Price	$239.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.84
Rate for Payer: Health Smart Auto/Commercial	$260.88
Rate for Payer: LLUH Dept of Risk Management WC	$239.14
Rate for Payer: Multiplan Commercial	$326.10

PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [108057]

Facility

$434.80

Service Code	HCPCS J9303
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$239.14
Max. Negotiated Rate	$347.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$260.88
Rate for Payer: Aetna of CA Government/Medicare	$260.88
Rate for Payer: Cash Price	$239.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$347.84
Rate for Payer: Health Smart Auto/Commercial	$260.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$260.88
Rate for Payer: LLUH Dept of Risk Management WC	$239.14
Rate for Payer: Multiplan Commercial	$326.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-01
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

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-11
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

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 31722-712-90
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 31722-712-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 13668-096-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 0378-6688-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.07

Service Code	NDC 65862-559-90
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	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 0378-6688-77
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-01
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

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.07

Service Code	NDC 65862-559-90
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	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
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	$0.04
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 Commercial	$0.05

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-11
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

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 13668-096-90
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]

Facility

$3.56

Service Code	HCPCS J2470
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$2.85
Rate for Payer: Cash Price	$1.96
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cash Price	$3.23
Rate for Payer: Cash Price	$3.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$2.14
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.53
Rate for Payer: Health Smart Auto/Commercial	$3.65
Rate for Payer: LLUH Dept of Risk Management WC	$3.23
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$1.96
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.35
Rate for Payer: Multiplan Commercial	$4.50
Rate for Payer: Multiplan Commercial	$4.41
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Commercial	$2.67
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$4.57

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]

Facility

$6.09

Service Code	HCPCS J2470
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$4.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.53
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$3.53
Rate for Payer: Aetna of CA Government/Medicare	$3.65
Rate for Payer: Aetna of CA Government/Medicare	$2.14
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$1.96
Rate for Payer: Cash Price	$3.23
Rate for Payer: Cash Price	$3.35
Rate for Payer: Cash Price	$6.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.87
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.14
Rate for Payer: Health Smart Auto/Commercial	$3.65
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$3.53
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.65
Rate for Payer: LLUH Dept of Risk Management WC	$3.23
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.35
Rate for Payer: LLUH Dept of Risk Management WC	$1.96
Rate for Payer: Multiplan Commercial	$4.41
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$4.57
Rate for Payer: Multiplan Commercial	$4.50
Rate for Payer: Multiplan Commercial	$9.00
Rate for Payer: Multiplan Commercial	$2.67

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.26

Service Code	NDC 60687-736-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.07

Service Code	NDC 65862-560-90
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	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.26

Service Code	NDC 60687-736-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.26

Service Code	NDC 60687-736-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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	$0.21
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	$0.14
Rate for Payer: Multiplan Commercial	$0.20

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.06

Service Code	NDC 65862-560-99
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

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.26

Service Code	NDC 60687-736-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

Know your out-of-pocket cost for care.

All Charges