Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F98.29
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F98.21
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F50.02
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F50.9
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F50.2
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F50.82
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

Medicare, Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 916

Facility

$535.00

Service Code	ICD F50.01
Hospital Revenue Code	916
Min. Negotiated Rate	$535.00
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna of CA Government/Medicare	$535.00

MEDIUM CHAIN TRIGLYCERIDES (MCT) 14 GRAM-120 KCAL/15 ML ORAL OIL [227248]

Facility

$0.03

Service Code	NDC 4009311257
Hospital Charge Code	NDG227248
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

MEDIUM CHAIN TRIGLYCERIDES (MCT) 14 GRAM-120 KCAL/15 ML ORAL OIL [227248]

Facility

$0.03

Service Code	NDC 4009311257
Hospital Charge Code	NDG227248
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$0.32

Service Code	NDC 59762-0056-1
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$1.68

Service Code	NDC 60687-105-11
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.26

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$0.32

Service Code	NDC 0555-0779-02
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$0.32

Service Code	NDC 59762-0056-1
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$1.68

Service Code	NDC 60687-105-21
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.26
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	$0.76
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 Beech St/Commercial/PHCS	$1.26

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$0.32

Service Code	NDC 0555-0779-02
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$0.32

Service Code	NDC 59762-3742-2
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$1.68

Service Code	NDC 60687-105-11
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.26
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	$0.76
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 Beech St/Commercial/PHCS	$1.26

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$0.32

Service Code	NDC 59762-3742-2
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

MEDROXYPROGESTERONE 10 MG TABLET [4854]

Facility

$1.68

Service Code	NDC 60687-105-21
Hospital Charge Code	1710307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.26

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE [114250]

Facility

$86.40

Service Code	CPT J1050
Hospital Charge Code	1712590
Hospital Revenue Code	636
Min. Negotiated Rate	$47.52
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.60
Rate for Payer: Aetna of CA Government/Medicare	$51.84
Rate for Payer: Aetna of CA Government/Medicare	$39.60
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cash Price	$38.88
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Health Smart Auto/Commercial	$51.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.84
Rate for Payer: LLUH Dept of Risk Management WC	$47.52
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE [114250]

Facility

$86.40

Service Code	CPT J1050
Hospital Charge Code	1712590
Hospital Revenue Code	636
Min. Negotiated Rate	$47.52
Max. Negotiated Rate	$69.12
Rate for Payer: Cash Price	$38.88
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna of CA HMO/PPO	$69.12
Rate for Payer: Cigna of CA HMO/PPO	$52.80
Rate for Payer: Health Smart Auto/Commercial	$51.84
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.52
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$0.17

Service Code	NDC 59762-0055-1
Hospital Charge Code	1711061
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

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$0.17

Service Code	NDC 0555-0872-02
Hospital Charge Code	1711061
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

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$0.17

Service Code	NDC 0555-0872-02
Hospital Charge Code	1711061
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

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$0.17

Service Code	NDC 59762-0055-1
Hospital Charge Code	1711061
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

Know your out-of-pocket cost for care.

All Charges