Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MIDODRINE 10 MG TABLET [33083]

Facility

$0.90

Service Code	NDC 68382-739-01
Hospital Charge Code	1711948
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

MIDODRINE 10 MG TABLET [33083]

Facility

$1.50

Service Code	NDC 0245-0213-11
Hospital Charge Code	1711948
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

MIDODRINE 10 MG TABLET [33083]

Facility

$1.50

Service Code	NDC 60505-1325-1
Hospital Charge Code	1711948
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

MIDODRINE 10 MG TABLET [33083]

Facility

$1.69

Service Code	NDC 60687-409-95
Hospital Charge Code	1711948
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.27
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	$0.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.27

MIDODRINE 10 MG TABLET [33083]

Facility

$1.69

Service Code	NDC 60687-409-25
Hospital Charge Code	1711948
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.35
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA HMO/PPO	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.27

MIDODRINE 2.5 MG TABLET [10609]

Facility

$0.63

Service Code	NDC 0245-0211-11
Hospital Charge Code	1712215
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

MIDODRINE 2.5 MG TABLET [10609]

Facility

$0.63

Service Code	NDC 0245-0211-11
Hospital Charge Code	1712215
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

MIDODRINE 5 MG TABLET [10610]

Facility

$1.37

Service Code	NDC 51079-453-20
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

MIDODRINE 5 MG TABLET [10610]

Facility

$0.54

Service Code	NDC 68382-738-01
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

MIDODRINE 5 MG TABLET [10610]

Facility

$1.37

Service Code	NDC 51079-453-01
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

MIDODRINE 5 MG TABLET [10610]

Facility

$1.37

Service Code	NDC 51079-453-01
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

MIDODRINE 5 MG TABLET [10610]

Facility

$0.54

Service Code	NDC 68382-738-01
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

MIDODRINE 5 MG TABLET [10610]

Facility

$1.37

Service Code	NDC 51079-453-20
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

MIDODRINE 5 MG TABLET [10610]

Facility

$1.96

Service Code	NDC 0378-1902-01
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.57
Rate for Payer: Cash Price	$0.88
Rate for Payer: Cigna of CA HMO/PPO	$1.57
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.47

MIDODRINE 5 MG TABLET [10610]

Facility

$1.96

Service Code	NDC 0378-1902-01
Hospital Charge Code	1712214
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.18
Rate for Payer: Aetna of CA Government/Medicare	$1.18
Rate for Payer: Cash Price	$0.88
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.47

MIDODRINE ORAL SOLUTION COMPOUND 1 MG/ML [40810610]

Facility

$0.48

Service Code	NDC 9994-8106-10
Hospital Charge Code	ERX40810610
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

MIDODRINE ORAL SOLUTION COMPOUND 1 MG/ML [40810610]

Facility

$0.48

Service Code	NDC 9994-8106-10
Hospital Charge Code	ERX40810610
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

MILRINONE 10 MG/50 ML D5.2NS SYRINGE [4080685]

Facility

$0.68

Service Code	CPT J2260
Hospital Charge Code	NDC4080685
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

MILRINONE 10 MG/50 ML D5.2NS SYRINGE [4080685]

Facility

$0.68

Service Code	CPT J2260
Hospital Charge Code	NDC4080685
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

MILRINONE 1MG/ML CONT INFUSION (UNDILUTED) [4080937]

Facility

$1.02

Service Code	CPT J2260
Hospital Charge Code	1759526
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

MILRINONE 1MG/ML CONT INFUSION (UNDILUTED) [4080937]

Facility

$0.96

Service Code	CPT J2260
Hospital Charge Code	NDG27327A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.72

MILRINONE 1MG/ML CONT INFUSION (UNDILUTED) [4080937]

Facility

$1.02

Service Code	CPT J2260
Hospital Charge Code	1759526
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.44
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

MILRINONE 1MG/ML CONT INFUSION (UNDILUTED) [4080937]

Facility

$0.96

Service Code	CPT J2260
Hospital Charge Code	NDG27327A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.43
Rate for Payer: Cigna of CA HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.72

MILRINONE 1 MG/ML INTRAVENOUS SOLUTION [27327]

Facility

$0.36

Service Code	CPT J2260
Hospital Charge Code	1759526
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

MILRINONE 1 MG/ML INTRAVENOUS SOLUTION [27327]

Facility

$0.55

Service Code	CPT J2260
Hospital Charge Code	1759526
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

Know your out-of-pocket cost for care.

All Charges