Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MEMANTINE 10 MG TABLET [36966]

Facility

$0.80

Service Code	NDC 60687-184-57
Hospital Charge Code	1711859
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

MEMANTINE 5 MG TABLET [37170]

Facility

$0.58

Service Code	NDC 60687-173-57
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

MEMANTINE 5 MG TABLET [37170]

Facility

$8.90

Service Code	NDC 0456-3205-60
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$6.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.34
Rate for Payer: Aetna of CA Government/Medicare	$5.34
Rate for Payer: Cash Price	$4.01
Rate for Payer: Health Smart Auto/Commercial	$5.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.34
Rate for Payer: LLUH Dept of Risk Management WC	$4.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.68

MEMANTINE 5 MG TABLET [37170]

Facility

$0.52

Service Code	NDC 0904-6505-61
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

MEMANTINE 5 MG TABLET [37170]

Facility

$0.22

Service Code	NDC 0832-1112-60
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

MEMANTINE 5 MG TABLET [37170]

Facility

$0.58

Service Code	NDC 60687-173-57
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

MEMANTINE 5 MG TABLET [37170]

Facility

$0.22

Service Code	NDC 0832-1112-60
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

MEMANTINE 5 MG TABLET [37170]

Facility

$0.58

Service Code	NDC 60687-173-11
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

MEMANTINE 5 MG TABLET [37170]

Facility

$0.52

Service Code	NDC 0904-6505-61
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

MEMANTINE 5 MG TABLET [37170]

Facility

$8.90

Service Code	NDC 0456-3205-60
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.12
Rate for Payer: Cash Price	$4.01
Rate for Payer: Cigna of CA HMO/PPO	$7.12
Rate for Payer: Health Smart Auto/Commercial	$5.34
Rate for Payer: LLUH Dept of Risk Management WC	$4.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.68

MEMANTINE 5 MG TABLET [37170]

Facility

$0.58

Service Code	NDC 60687-173-11
Hospital Charge Code	1711858
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]

Facility

$505.37

Service Code	CPT 90620
Hospital Charge Code	NDG208665
Hospital Revenue Code	636
Min. Negotiated Rate	$277.95
Max. Negotiated Rate	$404.30
Rate for Payer: Cash Price	$227.42
Rate for Payer: Cigna of CA HMO/PPO	$404.30
Rate for Payer: Health Smart Auto/Commercial	$303.22
Rate for Payer: LLUH Dept of Risk Management WC	$277.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$379.03

MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]

Facility

$505.37

Service Code	CPT 90620
Hospital Charge Code	NDG208665
Hospital Revenue Code	636
Min. Negotiated Rate	$277.95
Max. Negotiated Rate	$379.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$303.22
Rate for Payer: Aetna of CA Government/Medicare	$303.22
Rate for Payer: Cash Price	$227.42
Rate for Payer: Health Smart Auto/Commercial	$303.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$303.22
Rate for Payer: LLUH Dept of Risk Management WC	$277.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$379.03

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$354.57

Service Code	NDC 58160-827-30
Hospital Revenue Code	636
Min. Negotiated Rate	$195.01
Max. Negotiated Rate	$265.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$212.74
Rate for Payer: Aetna of CA Government/Medicare	$212.74
Rate for Payer: Cash Price	$159.56
Rate for Payer: Health Smart Auto/Commercial	$212.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$212.74
Rate for Payer: LLUH Dept of Risk Management WC	$195.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$265.93

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$354.57

Service Code	NDC 58160-827-30
Hospital Revenue Code	636
Min. Negotiated Rate	$195.01
Max. Negotiated Rate	$283.66
Rate for Payer: Cash Price	$159.56
Rate for Payer: Cigna of CA HMO/PPO	$283.66
Rate for Payer: Health Smart Auto/Commercial	$212.74
Rate for Payer: LLUH Dept of Risk Management WC	$195.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$265.93

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$354.57

Service Code	NDC 58160-827-03
Hospital Revenue Code	636
Min. Negotiated Rate	$195.01
Max. Negotiated Rate	$283.66
Rate for Payer: Cash Price	$159.56
Rate for Payer: Cigna of CA HMO/PPO	$283.66
Rate for Payer: Health Smart Auto/Commercial	$212.74
Rate for Payer: LLUH Dept of Risk Management WC	$195.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$265.93

MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]

Facility

$354.57

Service Code	NDC 58160-827-03
Hospital Revenue Code	636
Min. Negotiated Rate	$195.01
Max. Negotiated Rate	$265.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$212.74
Rate for Payer: Aetna of CA Government/Medicare	$212.74
Rate for Payer: Cash Price	$159.56
Rate for Payer: Health Smart Auto/Commercial	$212.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$212.74
Rate for Payer: LLUH Dept of Risk Management WC	$195.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$265.93

MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]

Facility

$304.80

Service Code	CPT 90734
Hospital Charge Code	ERX101034
Hospital Revenue Code	636
Min. Negotiated Rate	$167.64
Max. Negotiated Rate	$228.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$182.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.37
Rate for Payer: Aetna of CA Government/Medicare	$182.88
Rate for Payer: Aetna of CA Government/Medicare	$106.37
Rate for Payer: Cash Price	$137.16
Rate for Payer: Cash Price	$79.78
Rate for Payer: Health Smart Auto/Commercial	$106.37
Rate for Payer: Health Smart Auto/Commercial	$182.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$182.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.37
Rate for Payer: LLUH Dept of Risk Management WC	$97.51
Rate for Payer: LLUH Dept of Risk Management WC	$167.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$228.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$132.97

MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]

Facility

$177.29

Service Code	CPT 90734
Hospital Charge Code	ERX101034
Hospital Revenue Code	636
Min. Negotiated Rate	$97.51
Max. Negotiated Rate	$141.83
Rate for Payer: Cash Price	$79.78
Rate for Payer: Cash Price	$137.16
Rate for Payer: Cigna of CA HMO/PPO	$243.84
Rate for Payer: Cigna of CA HMO/PPO	$141.83
Rate for Payer: Health Smart Auto/Commercial	$182.88
Rate for Payer: Health Smart Auto/Commercial	$106.37
Rate for Payer: LLUH Dept of Risk Management WC	$167.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$228.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$132.97

MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION [40540]

Facility

$355.20

Service Code	CPT 90734
Hospital Charge Code	1721125
Hospital Revenue Code	636
Min. Negotiated Rate	$195.36
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$213.12
Rate for Payer: Aetna of CA Government/Medicare	$213.12
Rate for Payer: Cash Price	$159.84
Rate for Payer: Health Smart Auto/Commercial	$213.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$213.12
Rate for Payer: LLUH Dept of Risk Management WC	$195.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$266.40

MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION [40540]

Facility

$355.20

Service Code	CPT 90734
Hospital Charge Code	1721125
Hospital Revenue Code	636
Min. Negotiated Rate	$195.36
Max. Negotiated Rate	$284.16
Rate for Payer: Cash Price	$159.84
Rate for Payer: Cigna of CA HMO/PPO	$284.16
Rate for Payer: Health Smart Auto/Commercial	$213.12
Rate for Payer: LLUH Dept of Risk Management WC	$195.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$266.40

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]

Facility

$0.04

Service Code	NDC 10135-701-04
Hospital Charge Code	1743582
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
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	$0.03

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]

Facility

$0.04

Service Code	NDC 10135-701-04
Hospital Charge Code	1743582
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.02
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	$0.03

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]

Facility

$0.17

Service Code	NDC 0799-0001-05
Hospital Charge Code	NDG197109
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

MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]

Facility

$0.17

Service Code	NDC 0799-0001-05
Hospital Charge Code	NDG197109
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

Know your out-of-pocket cost for care.

All Charges