Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [225877]

Facility

$4,559.88

Service Code	CPT J0896
Hospital Charge Code	ERX225877
Hospital Revenue Code	636
Min. Negotiated Rate	$2,507.93
Max. Negotiated Rate	$3,419.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,735.93
Rate for Payer: Aetna of CA Government/Medicare	$2,735.93
Rate for Payer: Cash Price	$2,051.95
Rate for Payer: Health Smart Auto/Commercial	$2,735.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,735.93
Rate for Payer: LLUH Dept of Risk Management WC	$2,507.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,419.91

LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]

Facility

$13,679.62

Service Code	CPT J0896
Hospital Charge Code	ERX225879
Hospital Revenue Code	636
Min. Negotiated Rate	$7,523.79
Max. Negotiated Rate	$10,943.70
Rate for Payer: Cash Price	$6,155.83
Rate for Payer: Cigna of CA HMO/PPO	$10,943.70
Rate for Payer: Health Smart Auto/Commercial	$8,207.77
Rate for Payer: LLUH Dept of Risk Management WC	$7,523.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10,259.72

LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [225879]

Facility

$13,679.62

Service Code	CPT J0896
Hospital Charge Code	ERX225879
Hospital Revenue Code	636
Min. Negotiated Rate	$7,523.79
Max. Negotiated Rate	$10,259.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8,207.77
Rate for Payer: Aetna of CA Government/Medicare	$8,207.77
Rate for Payer: Cash Price	$6,155.83
Rate for Payer: Health Smart Auto/Commercial	$8,207.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8,207.77
Rate for Payer: LLUH Dept of Risk Management WC	$7,523.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10,259.72

LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]

Facility

$58,680.00

Service Code	CPT A9513
Hospital Charge Code	ERX220890
Hospital Revenue Code	344
Min. Negotiated Rate	$32,274.00
Max. Negotiated Rate	$44,010.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35,208.00
Rate for Payer: Aetna of CA Government/Medicare	$35,208.00
Rate for Payer: Cash Price	$26,406.00
Rate for Payer: Health Smart Auto/Commercial	$35,208.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35,208.00
Rate for Payer: LLUH Dept of Risk Management WC	$32,274.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44,010.00

LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [220890]

Facility

$58,680.00

Service Code	CPT A9513
Hospital Charge Code	ERX220890
Hospital Revenue Code	344
Min. Negotiated Rate	$32,274.00
Max. Negotiated Rate	$46,944.00
Rate for Payer: Cash Price	$26,406.00
Rate for Payer: Cigna of CA HMO/PPO	$46,944.00
Rate for Payer: Health Smart Auto/Commercial	$35,208.00
Rate for Payer: LLUH Dept of Risk Management WC	$32,274.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44,010.00

LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]

Facility

$52,020.00

Service Code	CPT A9607
Hospital Charge Code	NDG233901
Hospital Revenue Code	344
Min. Negotiated Rate	$28,611.00
Max. Negotiated Rate	$41,616.00
Rate for Payer: Cash Price	$23,409.00
Rate for Payer: Cigna of CA HMO/PPO	$41,616.00
Rate for Payer: Health Smart Auto/Commercial	$31,212.00
Rate for Payer: LLUH Dept of Risk Management WC	$28,611.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39,015.00

LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [233901]

Facility

$52,020.00

Service Code	CPT A9607
Hospital Charge Code	NDG233901
Hospital Revenue Code	344
Min. Negotiated Rate	$28,611.00
Max. Negotiated Rate	$39,015.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31,212.00
Rate for Payer: Aetna of CA Government/Medicare	$31,212.00
Rate for Payer: Cash Price	$23,409.00
Rate for Payer: Health Smart Auto/Commercial	$31,212.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31,212.00
Rate for Payer: LLUH Dept of Risk Management WC	$28,611.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39,015.00

MACITENTAN 10 MG TABLET [203952]

Facility

$447.39

Service Code	NDC 66215-501-30
Hospital Charge Code	ERX203952
Hospital Revenue Code	259
Min. Negotiated Rate	$246.06
Max. Negotiated Rate	$357.91
Rate for Payer: Cash Price	$201.33
Rate for Payer: Cigna of CA HMO/PPO	$357.91
Rate for Payer: Health Smart Auto/Commercial	$268.43
Rate for Payer: LLUH Dept of Risk Management WC	$246.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$335.54

MACITENTAN 10 MG TABLET [203952]

Facility

$447.39

Service Code	NDC 66215-501-15
Hospital Charge Code	ERX203952
Hospital Revenue Code	259
Min. Negotiated Rate	$246.06
Max. Negotiated Rate	$357.91
Rate for Payer: Cash Price	$201.33
Rate for Payer: Cigna of CA HMO/PPO	$357.91
Rate for Payer: Health Smart Auto/Commercial	$268.43
Rate for Payer: LLUH Dept of Risk Management WC	$246.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$335.54

MACITENTAN 10 MG TABLET [203952]

Facility

$447.39

Service Code	NDC 66215-501-30
Hospital Charge Code	ERX203952
Hospital Revenue Code	259
Min. Negotiated Rate	$246.06
Max. Negotiated Rate	$335.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$268.43
Rate for Payer: Aetna of CA Government/Medicare	$268.43
Rate for Payer: Cash Price	$201.33
Rate for Payer: Health Smart Auto/Commercial	$268.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$268.43
Rate for Payer: LLUH Dept of Risk Management WC	$246.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$335.54

MACITENTAN 10 MG TABLET [203952]

Facility

$447.39

Service Code	NDC 66215-501-15
Hospital Charge Code	ERX203952
Hospital Revenue Code	259
Min. Negotiated Rate	$246.06
Max. Negotiated Rate	$335.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$268.43
Rate for Payer: Aetna of CA Government/Medicare	$268.43
Rate for Payer: Cash Price	$201.33
Rate for Payer: Health Smart Auto/Commercial	$268.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$268.43
Rate for Payer: LLUH Dept of Risk Management WC	$246.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$335.54

MAFENIDE 50 GRAM TOPICAL PACKET [23233]

Facility

$167.95

Service Code	NDC 49884-902-52
Hospital Charge Code	1743697
Hospital Revenue Code	259
Min. Negotiated Rate	$92.37
Max. Negotiated Rate	$134.36
Rate for Payer: Cash Price	$75.58
Rate for Payer: Cigna of CA HMO/PPO	$134.36
Rate for Payer: Health Smart Auto/Commercial	$100.77
Rate for Payer: LLUH Dept of Risk Management WC	$92.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$125.96

MAFENIDE 50 GRAM TOPICAL PACKET [23233]

Facility

$167.95

Service Code	NDC 49884-902-52
Hospital Charge Code	1743697
Hospital Revenue Code	259
Min. Negotiated Rate	$92.37
Max. Negotiated Rate	$125.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$100.77
Rate for Payer: Aetna of CA Government/Medicare	$100.77
Rate for Payer: Cash Price	$75.58
Rate for Payer: Health Smart Auto/Commercial	$100.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$100.77
Rate for Payer: LLUH Dept of Risk Management WC	$92.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$125.96

MAFENIDE 85 MG/G TOPICAL CREAM [10478]

Facility

$1.23

Service Code	NDC 51079-623-82
Hospital Charge Code	1743480
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.92

MAFENIDE 85 MG/G TOPICAL CREAM [10478]

Facility

$1.28

Service Code	NDC 51079-623-81
Hospital Charge Code	NDG10478
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

MAFENIDE 85 MG/G TOPICAL CREAM [10478]

Facility

$1.28

Service Code	NDC 51079-623-81
Hospital Charge Code	NDG10478
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

MAFENIDE 85 MG/G TOPICAL CREAM [10478]

Facility

$1.23

Service Code	NDC 51079-623-82
Hospital Charge Code	1743480
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of CA HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.92

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 6858500575
Hospital Charge Code	1712587
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 1000670013
Hospital Charge Code	1712587
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 1000670013
Hospital Charge Code	1712587
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 6858500575
Hospital Charge Code	1712587
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [105730]

Facility

$0.17

Service Code	NDC 6761810760
Hospital Charge Code	1712588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.13

MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [105730]

Facility

$0.17

Service Code	NDC 6761810760
Hospital Charge Code	1712588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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	$0.08
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 Beech St/Commercial/PHCS	$0.13

MAGNESIUM CHLORIDE ORAL SOLUTION COMPOUND 2 MEQ/ML [4080294]

Facility

$0.11

Service Code	NDC 9994-0802-94
Hospital Charge Code	1715089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM CHLORIDE ORAL SOLUTION COMPOUND 2 MEQ/ML [4080294]

Facility

$0.11

Service Code	NDC 9994-0802-94
Hospital Charge Code	1715089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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	$0.05
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	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

Know your out-of-pocket cost for care.

All Charges