Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RUXOLITINIB 25 MG TABLET [153890]

Facility

$352.00

Service Code	NDC 50881-025-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 5 MG TABLET [153886]

Facility

$352.00

Service Code	NDC 50881-005-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$211.20
Rate for Payer: Aetna of CA Government/Medicare	$211.20
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 5 MG TABLET [153886]

Facility

$352.00

Service Code	NDC 50881-005-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]

Facility

$1.64

Service Code	NDC 62332-556-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.31
Rate for Payer: Cash Price	$0.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.31
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$1.23

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]

Facility

$14.10

Service Code	NDC 0078-0659-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.46
Rate for Payer: Aetna of CA Government/Medicare	$8.46
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]

Facility

$1.64

Service Code	NDC 62332-556-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.98
Rate for Payer: Aetna of CA Government/Medicare	$0.98
Rate for Payer: Cash Price	$0.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.31
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$1.23

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]

Facility

$14.10

Service Code	NDC 0078-0659-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$1.64

Service Code	NDC 62332-557-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.31
Rate for Payer: Cash Price	$0.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.31
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$1.23

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$14.10

Service Code	NDC 0078-0777-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.46
Rate for Payer: Aetna of CA Government/Medicare	$8.46
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$14.10

Service Code	NDC 0078-0777-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$1.64

Service Code	NDC 62332-557-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.98
Rate for Payer: Aetna of CA Government/Medicare	$0.98
Rate for Payer: Cash Price	$0.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.31
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$1.23

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$14.10

Service Code	NDC 0078-0777-67
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.46
Rate for Payer: Aetna of CA Government/Medicare	$8.46
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$14.10

Service Code	NDC 0078-0777-67
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]

Facility

$1.64

Service Code	NDC 62332-558-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.31
Rate for Payer: Cash Price	$0.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.31
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$1.23

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]

Facility

$14.10

Service Code	NDC 0078-0696-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.46
Rate for Payer: Aetna of CA Government/Medicare	$8.46
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]

Facility

$14.10

Service Code	NDC 0078-0696-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.28
Rate for Payer: Cash Price	$7.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.28
Rate for Payer: Health Smart Auto/Commercial	$8.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.75
Rate for Payer: Multiplan Commercial	$10.57

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]

Facility

$1.64

Service Code	NDC 62332-558-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.98
Rate for Payer: Aetna of CA Government/Medicare	$0.98
Rate for Payer: Cash Price	$0.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.31
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$1.23

SALICYLIC ACID 17 % TOPICAL LIQUID [11323]

Facility

$0.62

Service Code	NDC 1101725220
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.47

SALICYLIC ACID 17 % TOPICAL LIQUID [11323]

Facility

$0.62

Service Code	NDC 1101725220
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
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	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
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 Commercial	$0.47

SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]

Facility

$0.16

Service Code	NDC 4858251201
Hospital Charge Code	901700029
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	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
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	$0.12

SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]

Facility

$0.16

Service Code	NDC 4858251201
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
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	$0.12

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.33

Service Code	HCPCS A9154
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.33

Service Code	HCPCS A9154
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION [11338]

Facility

$377.55

Service Code	HCPCS J2820
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$207.65
Max. Negotiated Rate	$302.04
Rate for Payer: Cash Price	$207.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$302.04
Rate for Payer: Health Smart Auto/Commercial	$226.53
Rate for Payer: LLUH Dept of Risk Management WC	$207.65
Rate for Payer: Multiplan Commercial	$283.16

SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION [11338]

Facility

$377.55

Service Code	HCPCS J2820
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$207.65
Max. Negotiated Rate	$302.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$226.53
Rate for Payer: Aetna of CA Government/Medicare	$226.53
Rate for Payer: Cash Price	$207.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$302.04
Rate for Payer: Health Smart Auto/Commercial	$226.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$226.53
Rate for Payer: LLUH Dept of Risk Management WC	$207.65
Rate for Payer: Multiplan Commercial	$283.16

Know your out-of-pocket cost for care.

All Charges