Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BENZOYL PEROXIDE 5 % TOPICAL GEL [991]

Facility

$0.28

Service Code	NDC 45802-216-96
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

BENZTROPINE 0.5 MG TABLET [998]

Facility

$0.59

Service Code	NDC 68084-381-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
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	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
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 Commercial	$0.44

BENZTROPINE 0.5 MG TABLET [998]

Facility

$0.17

Service Code	NDC 0603-2433-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
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	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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 Commercial	$0.13

BENZTROPINE 0.5 MG TABLET [998]

Facility

$0.59

Service Code	NDC 68084-381-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

BENZTROPINE 0.5 MG TABLET [998]

Facility

$0.59

Service Code	NDC 68084-381-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
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	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
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 Commercial	$0.44

BENZTROPINE 0.5 MG TABLET [998]

Facility

$0.17

Service Code	NDC 0603-2433-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.13

BENZTROPINE 0.5 MG TABLET [998]

Facility

$0.59

Service Code	NDC 68084-381-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]

Facility

$36.00

Service Code	HCPCS J0515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.92
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$16.92
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$15.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.56
Rate for Payer: Health Smart Auto/Commercial	$16.92
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.51
Rate for Payer: Multiplan Commercial	$27.00
Rate for Payer: Multiplan Commercial	$21.15

BENZTROPINE 1 MG/ML INJECTION SOLUTION [9259]

Facility

$36.00

Service Code	HCPCS J0515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$15.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$16.92
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.51
Rate for Payer: Multiplan Commercial	$21.15
Rate for Payer: Multiplan Commercial	$27.00

BENZTROPINE 1 MG TABLET [999]

Facility

$0.19

Service Code	NDC 69315-137-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

BENZTROPINE 1 MG TABLET [999]

Facility

$0.19

Service Code	NDC 0603-2434-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

BENZTROPINE 1 MG TABLET [999]

Facility

$0.19

Service Code	NDC 0603-2434-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

BENZTROPINE 1 MG TABLET [999]

Facility

$0.19

Service Code	NDC 69315-137-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]

Facility

$10.48

Service Code	HCPCS J0702
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$8.38
Rate for Payer: Cash Price	$5.76
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.38
Rate for Payer: Health Smart Auto/Commercial	$6.29
Rate for Payer: Health Smart Auto/Commercial	$7.93
Rate for Payer: LLUH Dept of Risk Management WC	$5.76
Rate for Payer: LLUH Dept of Risk Management WC	$7.27
Rate for Payer: Multiplan Commercial	$9.91
Rate for Payer: Multiplan Commercial	$7.86

BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]

Facility

$10.48

Service Code	HCPCS J0702
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$8.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.93
Rate for Payer: Aetna of CA Government/Medicare	$6.29
Rate for Payer: Aetna of CA Government/Medicare	$7.93
Rate for Payer: Cash Price	$5.76
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.57
Rate for Payer: Health Smart Auto/Commercial	$6.29
Rate for Payer: Health Smart Auto/Commercial	$7.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.93
Rate for Payer: LLUH Dept of Risk Management WC	$7.27
Rate for Payer: LLUH Dept of Risk Management WC	$5.76
Rate for Payer: Multiplan Commercial	$7.86
Rate for Payer: Multiplan Commercial	$9.91

BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]

Facility

$2.84

Service Code	NDC 0472-0382-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.70
Rate for Payer: Aetna of CA Government/Medicare	$1.70
Rate for Payer: Cash Price	$1.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Commercial	$2.13

BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT [9178]

Facility

$2.84

Service Code	NDC 0472-0382-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Cash Price	$1.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Commercial	$2.13

BETAMETHASONE DIPROPIONATE 0.05 % LOTION [1028]

Facility

$0.80

Service Code	NDC 0168-0057-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
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	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
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 Commercial	$0.60

BETAMETHASONE DIPROPIONATE 0.05 % LOTION [1028]

Facility

$0.80

Service Code	NDC 0168-0057-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM [1027]

Facility

$2.59

Service Code	NDC 0472-0380-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.55
Rate for Payer: Aetna of CA Government/Medicare	$1.55
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.07
Rate for Payer: Health Smart Auto/Commercial	$1.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.55
Rate for Payer: LLUH Dept of Risk Management WC	$1.42
Rate for Payer: Multiplan Commercial	$1.94

BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM [1027]

Facility

$2.59

Service Code	NDC 0472-0380-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.07
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.07
Rate for Payer: Health Smart Auto/Commercial	$1.55
Rate for Payer: LLUH Dept of Risk Management WC	$1.42
Rate for Payer: Multiplan Commercial	$1.94

BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]

Facility

$3.94

Service Code	NDC 0168-0056-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]

Facility

$3.14

Service Code	NDC 0472-0381-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.88
Rate for Payer: Aetna of CA Government/Medicare	$1.88
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.51
Rate for Payer: Health Smart Auto/Commercial	$1.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.88
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.35

BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]

Facility

$3.14

Service Code	NDC 0472-0381-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.51
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.51
Rate for Payer: Health Smart Auto/Commercial	$1.88
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.35

BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [1029]

Facility

$3.94

Service Code	NDC 0168-0056-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.36
Rate for Payer: Aetna of CA Government/Medicare	$2.36
Rate for Payer: Cash Price	$2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

Know your out-of-pocket cost for care.

All Charges