Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MIRTAZAPINE 30 MG TABLET [17465]

Facility

$0.40

Service Code	NDC 68084-120-01
Hospital Charge Code	1713136
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

MIRTAZAPINE 30 MG TABLET [17465]

Facility

$0.40

Service Code	NDC 68084-120-01
Hospital Charge Code	1713136
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 9999-9384-21
Hospital Charge Code	1712402
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.05
Rate for Payer: Cash Price	$1.15
Rate for Payer: Cigna of CA HMO/PPO	$2.05
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.92

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 13107-001-30
Hospital Charge Code	1712402
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.92

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.49

Service Code	NDC 57664-510-83
Hospital Charge Code	1712402
Hospital Revenue Code	259
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.49
Rate for Payer: Aetna of CA Government/Medicare	$1.49
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Smart Auto/Commercial	$1.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.49
Rate for Payer: LLUH Dept of Risk Management WC	$1.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.87

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.49

Service Code	NDC 57664-510-83
Hospital Charge Code	1712402
Hospital Revenue Code	259
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.99
Rate for Payer: Cash Price	$1.12
Rate for Payer: Cigna of CA HMO/PPO	$1.99
Rate for Payer: Health Smart Auto/Commercial	$1.49
Rate for Payer: LLUH Dept of Risk Management WC	$1.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.87

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 9999-9384-21
Hospital Charge Code	1712402
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.92

MIRTAZAPINE 7.5 MG TABLET [38421]

Facility

$2.56

Service Code	NDC 13107-001-30
Hospital Charge Code	1712402
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.05
Rate for Payer: Cash Price	$1.15
Rate for Payer: Cigna of CA HMO/PPO	$2.05
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.92

MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]

Facility

$373.20

Service Code	NDC 72903-853-01
Hospital Charge Code	NDG236274
Hospital Revenue Code	636
Min. Negotiated Rate	$205.26
Max. Negotiated Rate	$298.56
Rate for Payer: Cash Price	$167.94
Rate for Payer: Cigna of CA HMO/PPO	$298.56
Rate for Payer: Health Smart Auto/Commercial	$223.92
Rate for Payer: LLUH Dept of Risk Management WC	$205.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$279.90

MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]

Facility

$373.20

Service Code	NDC 72903-853-01
Hospital Charge Code	NDG236274
Hospital Revenue Code	636
Min. Negotiated Rate	$205.26
Max. Negotiated Rate	$279.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$223.92
Rate for Payer: Aetna of CA Government/Medicare	$223.92
Rate for Payer: Cash Price	$167.94
Rate for Payer: Health Smart Auto/Commercial	$223.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$223.92
Rate for Payer: LLUH Dept of Risk Management WC	$205.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$279.90

MISOPROSTOL 100 MCG TABLET [10628]

Facility

$0.79

Service Code	CPT S0191
Hospital Charge Code	1711502
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

MISOPROSTOL 100 MCG TABLET [10628]

Facility

$0.79

Service Code	CPT S0191
Hospital Charge Code	1711502
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.47
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

MISOPROSTOL 100MCGX10TABLET KIT [4081172]

Facility

$9.88

Service Code	CPT S0191
Hospital Charge Code	NDG10628
Hospital Revenue Code	636
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$7.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.93
Rate for Payer: Aetna of CA Government/Medicare	$5.93
Rate for Payer: Cash Price	$4.45
Rate for Payer: Health Smart Auto/Commercial	$5.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.93
Rate for Payer: LLUH Dept of Risk Management WC	$5.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.41

MISOPROSTOL 100MCGX10TABLET KIT [4081172]

Facility

$9.88

Service Code	CPT S0191
Hospital Charge Code	NDG10628
Hospital Revenue Code	636
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$7.90
Rate for Payer: Cash Price	$4.45
Rate for Payer: Cigna of CA HMO/PPO	$7.90
Rate for Payer: Health Smart Auto/Commercial	$5.93
Rate for Payer: LLUH Dept of Risk Management WC	$5.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.41

MISOPROSTOL 200 MCG TABLET [10629]

Facility

$1.16

Service Code	CPT S0191
Hospital Charge Code	1711307
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.87

MISOPROSTOL 200 MCG TABLET [10629]

Facility

$1.16

Service Code	CPT S0191
Hospital Charge Code	1711307
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna of CA HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.87

MISOPROSTOL 200MCGX5TABLET KIT [4081585]

Facility

$0.25

Service Code	CPT S0191
Hospital Charge Code	ERX4081585
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

MISOPROSTOL 200MCGX5TABLET KIT [4081585]

Facility

$0.25

Service Code	CPT S0191
Hospital Charge Code	ERX4081585
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

MISOPROSTOL 25 MCG 1/4 TAB [4080523]

Facility

$0.62

Service Code	CPT S0191
Hospital Charge Code	1712404
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

MISOPROSTOL 25 MCG 1/4 TAB [4080523]

Facility

$0.62

Service Code	CPT S0191
Hospital Charge Code	1712404
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
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	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]

Facility

$430.80

Service Code	CPT J7315
Hospital Charge Code	ERX196257
Hospital Revenue Code	636
Min. Negotiated Rate	$236.94
Max. Negotiated Rate	$344.64
Rate for Payer: Cash Price	$193.86
Rate for Payer: Cigna of CA HMO/PPO	$344.64
Rate for Payer: Health Smart Auto/Commercial	$258.48
Rate for Payer: LLUH Dept of Risk Management WC	$236.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$323.10

MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]

Facility

$430.80

Service Code	CPT J7315
Hospital Charge Code	ERX196257
Hospital Revenue Code	636
Min. Negotiated Rate	$236.94
Max. Negotiated Rate	$323.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$258.48
Rate for Payer: Aetna of CA Government/Medicare	$258.48
Rate for Payer: Cash Price	$193.86
Rate for Payer: Health Smart Auto/Commercial	$258.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$258.48
Rate for Payer: LLUH Dept of Risk Management WC	$236.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$323.10

MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]

Facility

$758.40

Service Code	CPT J9280
Hospital Charge Code	1755047
Hospital Revenue Code	636
Min. Negotiated Rate	$417.12
Max. Negotiated Rate	$606.72
Rate for Payer: Cash Price	$341.28
Rate for Payer: Cash Price	$341.27
Rate for Payer: Cigna of CA HMO/PPO	$606.72
Rate for Payer: Cigna of CA HMO/PPO	$606.70
Rate for Payer: Health Smart Auto/Commercial	$455.03
Rate for Payer: Health Smart Auto/Commercial	$455.04
Rate for Payer: LLUH Dept of Risk Management WC	$417.11
Rate for Payer: LLUH Dept of Risk Management WC	$417.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$568.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$568.78

MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]

Facility

$758.40

Service Code	CPT J9280
Hospital Charge Code	1755047
Hospital Revenue Code	636
Min. Negotiated Rate	$417.12
Max. Negotiated Rate	$568.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$455.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$455.03
Rate for Payer: Aetna of CA Government/Medicare	$455.04
Rate for Payer: Aetna of CA Government/Medicare	$455.03
Rate for Payer: Cash Price	$341.27
Rate for Payer: Cash Price	$341.28
Rate for Payer: Health Smart Auto/Commercial	$455.04
Rate for Payer: Health Smart Auto/Commercial	$455.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$455.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$455.04
Rate for Payer: LLUH Dept of Risk Management WC	$417.11
Rate for Payer: LLUH Dept of Risk Management WC	$417.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$568.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$568.78

MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]

Facility

$1,516.75

Service Code	CPT J9280
Hospital Charge Code	ERX10631
Hospital Revenue Code	636
Min. Negotiated Rate	$834.21
Max. Negotiated Rate	$1,213.40
Rate for Payer: Cash Price	$682.54
Rate for Payer: Cash Price	$682.56
Rate for Payer: Cigna of CA HMO/PPO	$1,213.40
Rate for Payer: Cigna of CA HMO/PPO	$1,213.44
Rate for Payer: Health Smart Auto/Commercial	$910.08
Rate for Payer: Health Smart Auto/Commercial	$910.05
Rate for Payer: LLUH Dept of Risk Management WC	$834.21
Rate for Payer: LLUH Dept of Risk Management WC	$834.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,137.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,137.60

Know your out-of-pocket cost for care.

All Charges