Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [114051]

Facility

$0.25

Service Code	CPT J2020
Hospital Charge Code	1753528
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [114051]

Facility

$0.25

Service Code	CPT J2020
Hospital Charge Code	1753528
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION [10442]

Facility

$493.54

Service Code	NDC 42023-120-01
Hospital Charge Code	NDG10442
Hospital Revenue Code	250
Min. Negotiated Rate	$271.45
Max. Negotiated Rate	$394.83
Rate for Payer: Cash Price	$222.09
Rate for Payer: Cigna of CA HMO/PPO	$394.83
Rate for Payer: Health Smart Auto/Commercial	$296.12
Rate for Payer: LLUH Dept of Risk Management WC	$271.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$370.16

LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION [10442]

Facility

$493.54

Service Code	NDC 42023-120-01
Hospital Charge Code	NDG10442
Hospital Revenue Code	250
Min. Negotiated Rate	$271.45
Max. Negotiated Rate	$370.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$296.12
Rate for Payer: Aetna of CA Government/Medicare	$296.12
Rate for Payer: Cash Price	$222.09
Rate for Payer: Health Smart Auto/Commercial	$296.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$296.12
Rate for Payer: LLUH Dept of Risk Management WC	$271.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$370.16

LIOTHYRONINE 25 MCG TABLET [4504]

Facility

$1.06

Service Code	NDC 42794-019-12
Hospital Charge Code	1710808
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

LIOTHYRONINE 25 MCG TABLET [4504]

Facility

$0.87

Service Code	NDC 62756-590-88
Hospital Charge Code	1710808
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

LIOTHYRONINE 25 MCG TABLET [4504]

Facility

$0.87

Service Code	NDC 62756-590-88
Hospital Charge Code	1710808
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.65
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	$0.39
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	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

LIOTHYRONINE 25 MCG TABLET [4504]

Facility

$1.06

Service Code	NDC 42794-019-12
Hospital Charge Code	1710808
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.85
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cigna of CA HMO/PPO	$0.85
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

LIOTHYRONINE 5 MCG TABLET [10443]

Facility

$0.82

Service Code	NDC 42794-018-12
Hospital Charge Code	1710809
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

LIOTHYRONINE 5 MCG TABLET [10443]

Facility

$0.82

Service Code	NDC 42794-018-12
Hospital Charge Code	1710809
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]

Facility

$4.75

Service Code	NDC 0032-1212-07
Hospital Charge Code	1712413
Hospital Revenue Code	259
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cigna of CA HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]

Facility

$4.75

Service Code	NDC 0032-1212-01
Hospital Charge Code	1712413
Hospital Revenue Code	259
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.85
Rate for Payer: Aetna of CA Government/Medicare	$2.85
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]

Facility

$4.75

Service Code	NDC 0032-1212-01
Hospital Charge Code	1712413
Hospital Revenue Code	259
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cigna of CA HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]

Facility

$4.75

Service Code	NDC 0032-1212-07
Hospital Charge Code	1712413
Hospital Revenue Code	259
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.85
Rate for Payer: Aetna of CA Government/Medicare	$2.85
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

LIPASE-PROTEASE-AMYLASE 20,880-78,300-78,300 UNIT TABLET [196333]

Facility

$9.14

Service Code	NDC 73562-208-10
Hospital Charge Code	1712582
Hospital Revenue Code	259
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$7.31
Rate for Payer: Cash Price	$4.11
Rate for Payer: Cigna of CA HMO/PPO	$7.31
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.86

LIPASE-PROTEASE-AMYLASE 20,880-78,300-78,300 UNIT TABLET [196333]

Facility

$9.14

Service Code	NDC 73562-208-10
Hospital Charge Code	1712582
Hospital Revenue Code	259
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$6.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.48
Rate for Payer: Aetna of CA Government/Medicare	$5.48
Rate for Payer: Cash Price	$4.11
Rate for Payer: Health Smart Auto/Commercial	$5.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.86

LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]

Facility

$9.41

Service Code	NDC 0032-1224-01
Hospital Charge Code	1712414
Hospital Revenue Code	259
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$7.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.65
Rate for Payer: Aetna of CA Government/Medicare	$5.65
Rate for Payer: Cash Price	$4.23
Rate for Payer: Health Smart Auto/Commercial	$5.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.65
Rate for Payer: LLUH Dept of Risk Management WC	$5.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.06

LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]

Facility

$9.26

Service Code	NDC 0032-1224-07
Hospital Charge Code	1712414
Hospital Revenue Code	259
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$6.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.56
Rate for Payer: Aetna of CA Government/Medicare	$5.56
Rate for Payer: Cash Price	$4.17
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.94

LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]

Facility

$9.26

Service Code	NDC 0032-1224-07
Hospital Charge Code	1712414
Hospital Revenue Code	259
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$7.41
Rate for Payer: Cash Price	$4.17
Rate for Payer: Cigna of CA HMO/PPO	$7.41
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.94

LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]

Facility

$9.41

Service Code	NDC 0032-1224-01
Hospital Charge Code	1712414
Hospital Revenue Code	259
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$7.53
Rate for Payer: Cash Price	$4.23
Rate for Payer: Cigna of CA HMO/PPO	$7.53
Rate for Payer: Health Smart Auto/Commercial	$5.65
Rate for Payer: LLUH Dept of Risk Management WC	$5.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.06

LIPASE-PROTEASE-AMYLASE 3,000-9,500-15,000 UNIT CAPSULE, DELAYED REL [187996]

Facility

$2.01

Service Code	NDC 0032-1203-70
Hospital Charge Code	1712583
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.51

LIPASE-PROTEASE-AMYLASE 3,000-9,500-15,000 UNIT CAPSULE, DELAYED REL [187996]

Facility

$2.01

Service Code	NDC 0032-1203-70
Hospital Charge Code	1712583
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.51

LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL [201958]

Facility

$14.28

Service Code	NDC 0032-3016-28
Hospital Charge Code	ERX201958
Hospital Revenue Code	259
Min. Negotiated Rate	$7.85
Max. Negotiated Rate	$11.42
Rate for Payer: Cash Price	$6.43
Rate for Payer: Cigna of CA HMO/PPO	$11.42
Rate for Payer: Health Smart Auto/Commercial	$8.57
Rate for Payer: LLUH Dept of Risk Management WC	$7.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.71

LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL [201958]

Facility

$14.28

Service Code	NDC 0032-3016-28
Hospital Charge Code	ERX201958
Hospital Revenue Code	259
Min. Negotiated Rate	$7.85
Max. Negotiated Rate	$10.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.57
Rate for Payer: Aetna of CA Government/Medicare	$8.57
Rate for Payer: Cash Price	$6.43
Rate for Payer: Health Smart Auto/Commercial	$8.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.57
Rate for Payer: LLUH Dept of Risk Management WC	$7.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.71

LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL [98034]

Facility

$2.38

Service Code	NDC 0032-1206-07
Hospital Charge Code	1712412
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.07
Rate for Payer: Cigna of CA HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.78

Know your out-of-pocket cost for care.

All Charges