Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]

Facility

$27,872.40

Service Code	CPT J9281
Hospital Charge Code	ERX227769
Hospital Revenue Code	636
Min. Negotiated Rate	$15,329.82
Max. Negotiated Rate	$20,904.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16,723.44
Rate for Payer: Aetna of CA Government/Medicare	$16,723.44
Rate for Payer: Cash Price	$12,542.58
Rate for Payer: Health Smart Auto/Commercial	$16,723.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16,723.44
Rate for Payer: LLUH Dept of Risk Management WC	$15,329.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20,904.30

MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]

Facility

$27,872.40

Service Code	CPT J9281
Hospital Charge Code	ERX227769
Hospital Revenue Code	636
Min. Negotiated Rate	$15,329.82
Max. Negotiated Rate	$22,297.92
Rate for Payer: Cash Price	$12,542.58
Rate for Payer: Cigna of CA HMO/PPO	$22,297.92
Rate for Payer: Health Smart Auto/Commercial	$16,723.44
Rate for Payer: LLUH Dept of Risk Management WC	$15,329.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20,904.30

MITOMYCIN (BULK) POWDER [24011]

Facility

$56,293.48

Service Code	NDC 38779-0553-6
Hospital Charge Code	NDG24011
Hospital Revenue Code	259
Min. Negotiated Rate	$30,961.41
Max. Negotiated Rate	$42,220.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33,776.09
Rate for Payer: Aetna of CA Government/Medicare	$33,776.09
Rate for Payer: Cash Price	$25,332.07
Rate for Payer: Health Smart Auto/Commercial	$33,776.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33,776.09
Rate for Payer: LLUH Dept of Risk Management WC	$30,961.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42,220.11

MITOMYCIN (BULK) POWDER [24011]

Facility

$56,293.48

Service Code	NDC 38779-0553-6
Hospital Charge Code	NDG24011
Hospital Revenue Code	259
Min. Negotiated Rate	$30,961.41
Max. Negotiated Rate	$45,034.78
Rate for Payer: Cash Price	$25,332.07
Rate for Payer: Cigna of CA HMO/PPO	$45,034.78
Rate for Payer: Health Smart Auto/Commercial	$33,776.09
Rate for Payer: LLUH Dept of Risk Management WC	$30,961.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42,220.11

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-15
Hospital Charge Code	NDC4080715
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.60
Rate for Payer: Cash Price	$5.96
Rate for Payer: Cigna of CA HMO/PPO	$10.60
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-17
Hospital Charge Code	ERX4080715
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$9.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.95
Rate for Payer: Aetna of CA Government/Medicare	$7.95
Rate for Payer: Cash Price	$5.96
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-15
Hospital Charge Code	NDC4080715
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$9.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.95
Rate for Payer: Aetna of CA Government/Medicare	$7.95
Rate for Payer: Cash Price	$5.96
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.94

MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]

Facility

$13.25

Service Code	NDC 9994-0807-17
Hospital Charge Code	ERX4080715
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.60
Rate for Payer: Cash Price	$5.96
Rate for Payer: Cigna of CA HMO/PPO	$10.60
Rate for Payer: Health Smart Auto/Commercial	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.94

MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]

Facility

$142.55

Service Code	NDC 9994-0807-16
Hospital Charge Code	ERX4080716
Hospital Revenue Code	259
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$106.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.53
Rate for Payer: Aetna of CA Government/Medicare	$85.53
Rate for Payer: Cash Price	$64.15
Rate for Payer: Health Smart Auto/Commercial	$85.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.53
Rate for Payer: LLUH Dept of Risk Management WC	$78.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$106.91

MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]

Facility

$142.55

Service Code	NDC 9994-0807-16
Hospital Charge Code	ERX4080716
Hospital Revenue Code	259
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$114.04
Rate for Payer: Cash Price	$64.15
Rate for Payer: Cigna of CA HMO/PPO	$114.04
Rate for Payer: Health Smart Auto/Commercial	$85.53
Rate for Payer: LLUH Dept of Risk Management WC	$78.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$106.91

MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]

Facility

$2.90

Service Code	NDC 9994-0810-78
Hospital Charge Code	NDG4081078
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.32
Rate for Payer: Cash Price	$1.31
Rate for Payer: Cigna of CA HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.18

MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]

Facility

$2.90

Service Code	NDC 9994-0810-78
Hospital Charge Code	NDG4081078
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.74
Rate for Payer: Aetna of CA Government/Medicare	$1.74
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.18

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$25.98

Service Code	CPT J9293
Hospital Charge Code	NDG10634A
Hospital Revenue Code	636
Min. Negotiated Rate	$14.29
Max. Negotiated Rate	$19.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.59
Rate for Payer: Aetna of CA Government/Medicare	$15.59
Rate for Payer: Cash Price	$11.69
Rate for Payer: Health Smart Auto/Commercial	$15.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.59
Rate for Payer: LLUH Dept of Risk Management WC	$14.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.48

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$20.71

Service Code	CPT J9293
Hospital Charge Code	1755456
Hospital Revenue Code	636
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$15.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.43
Rate for Payer: Aetna of CA Government/Medicare	$12.43
Rate for Payer: Cash Price	$9.32
Rate for Payer: Health Smart Auto/Commercial	$12.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.43
Rate for Payer: LLUH Dept of Risk Management WC	$11.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.53

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$25.98

Service Code	CPT J9293
Hospital Charge Code	NDG10634A
Hospital Revenue Code	636
Min. Negotiated Rate	$14.29
Max. Negotiated Rate	$20.78
Rate for Payer: Cash Price	$11.69
Rate for Payer: Cigna of CA HMO/PPO	$20.78
Rate for Payer: Health Smart Auto/Commercial	$15.59
Rate for Payer: LLUH Dept of Risk Management WC	$14.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.48

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$51.00

Service Code	CPT J9293
Hospital Charge Code	NDG10634B
Hospital Revenue Code	636
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$38.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.60
Rate for Payer: Aetna of CA Government/Medicare	$30.60
Rate for Payer: Cash Price	$22.95
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.25

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$20.71

Service Code	CPT J9293
Hospital Charge Code	1755456
Hospital Revenue Code	636
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$16.57
Rate for Payer: Cash Price	$9.32
Rate for Payer: Cigna of CA HMO/PPO	$16.57
Rate for Payer: Health Smart Auto/Commercial	$12.43
Rate for Payer: LLUH Dept of Risk Management WC	$11.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.53

MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]

Facility

$51.00

Service Code	CPT J9293
Hospital Charge Code	NDG10634B
Hospital Revenue Code	636
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$40.80
Rate for Payer: Cigna of CA HMO/PPO	$40.80
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Cash Price	$22.95
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.25

MOBOCERTINIB 40 MG CAPSULE [232787]

Facility

$267.50

Service Code	NDC 63020-040-12
Hospital Charge Code	ERX232787
Hospital Revenue Code	259
Min. Negotiated Rate	$147.12
Max. Negotiated Rate	$214.00
Rate for Payer: Cash Price	$120.38
Rate for Payer: Cigna of CA HMO/PPO	$214.00
Rate for Payer: Health Smart Auto/Commercial	$160.50
Rate for Payer: LLUH Dept of Risk Management WC	$147.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.62

MOBOCERTINIB 40 MG CAPSULE [232787]

Facility

$267.50

Service Code	NDC 63020-040-12
Hospital Charge Code	ERX232787
Hospital Revenue Code	259
Min. Negotiated Rate	$147.12
Max. Negotiated Rate	$200.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.50
Rate for Payer: Aetna of CA Government/Medicare	$160.50
Rate for Payer: Cash Price	$120.38
Rate for Payer: Health Smart Auto/Commercial	$160.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.50
Rate for Payer: LLUH Dept of Risk Management WC	$147.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.62

MODAFINIL 100 MG TABLET [24702]

Facility

$0.36

Service Code	NDC 69452-342-13
Hospital Charge Code	1731017
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
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: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

MODAFINIL 100 MG TABLET [24702]

Facility

$13.20

Service Code	NDC 68084-621-21
Hospital Charge Code	1731017
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of CA HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.90

MODAFINIL 100 MG TABLET [24702]

Facility

$13.20

Service Code	NDC 68084-621-11
Hospital Charge Code	1731017
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of CA HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.90

MODAFINIL 100 MG TABLET [24702]

Facility

$0.36

Service Code	NDC 69452-342-13
Hospital Charge Code	1731017
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

Know your out-of-pocket cost for care.

All Charges