Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.18

Service Code	NDC 68180-545-02
Hospital Charge Code	1743543
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$5.37

Service Code	NDC 0168-0081-15
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$4.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.22
Rate for Payer: Aetna of CA Government/Medicare	$3.22
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Smart Auto/Commercial	$3.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.03

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.18

Service Code	NDC 51672-1263-2
Hospital Charge Code	1743543
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.68

Service Code	NDC 51672-1263-1
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.26
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	$0.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.26

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$5.10

Service Code	NDC 0472-0150-30
Hospital Charge Code	1743543
Hospital Revenue Code	259
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.06
Rate for Payer: Aetna of CA Government/Medicare	$3.06
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Smart Auto/Commercial	$3.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.06
Rate for Payer: LLUH Dept of Risk Management WC	$2.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.82

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$7.16

Service Code	NDC 0472-0150-15
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.73
Rate for Payer: Cash Price	$3.22
Rate for Payer: Cigna of CA HMO/PPO	$5.73
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.37

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$7.16

Service Code	NDC 0472-0150-15
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.30
Rate for Payer: Aetna of CA Government/Medicare	$4.30
Rate for Payer: Cash Price	$3.22
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.37

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.68

Service Code	NDC 51672-1263-1
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.26

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$5.10

Service Code	NDC 0472-0150-30
Hospital Charge Code	1743543
Hospital Revenue Code	259
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.08
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna of CA HMO/PPO	$4.08
Rate for Payer: Health Smart Auto/Commercial	$3.06
Rate for Payer: LLUH Dept of Risk Management WC	$2.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.82

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$1.18

Service Code	NDC 68180-545-02
Hospital Charge Code	1743543
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$5.37

Service Code	NDC 0168-0081-15
Hospital Charge Code	1743540
Hospital Revenue Code	259
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$4.30
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cigna of CA HMO/PPO	$4.30
Rate for Payer: Health Smart Auto/Commercial	$3.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.03

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

$1.01

Service Code	NDC 68462-799-17
Hospital Charge Code	1743557
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.76

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

$1.01

Service Code	NDC 68462-799-17
Hospital Charge Code	1743557
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.76

OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]

Facility

$233.26

Service Code	CPT J9301
Hospital Charge Code	NDG204196
Hospital Revenue Code	636
Min. Negotiated Rate	$128.29
Max. Negotiated Rate	$174.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.96
Rate for Payer: Aetna of CA Government/Medicare	$139.96
Rate for Payer: Cash Price	$104.97
Rate for Payer: Health Smart Auto/Commercial	$139.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.96
Rate for Payer: LLUH Dept of Risk Management WC	$128.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.94

OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]

Facility

$233.26

Service Code	CPT J9301
Hospital Charge Code	NDG204196
Hospital Revenue Code	636
Min. Negotiated Rate	$128.29
Max. Negotiated Rate	$186.61
Rate for Payer: Cash Price	$104.97
Rate for Payer: Cigna of CA HMO/PPO	$186.61
Rate for Payer: Health Smart Auto/Commercial	$139.96
Rate for Payer: LLUH Dept of Risk Management WC	$128.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.94

OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION [216963]

Facility

$2,253.07

Service Code	CPT J2350
Hospital Charge Code	NDG216963
Hospital Revenue Code	636
Min. Negotiated Rate	$1,239.19
Max. Negotiated Rate	$1,689.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,351.84
Rate for Payer: Aetna of CA Government/Medicare	$1,351.84
Rate for Payer: Cash Price	$1,013.88
Rate for Payer: Health Smart Auto/Commercial	$1,351.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,351.84
Rate for Payer: LLUH Dept of Risk Management WC	$1,239.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,689.80

OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION [216963]

Facility

$2,253.07

Service Code	CPT J2350
Hospital Charge Code	NDG216963
Hospital Revenue Code	636
Min. Negotiated Rate	$1,239.19
Max. Negotiated Rate	$1,802.46
Rate for Payer: Cash Price	$1,013.88
Rate for Payer: Cigna of CA HMO/PPO	$1,802.46
Rate for Payer: Health Smart Auto/Commercial	$1,351.84
Rate for Payer: LLUH Dept of Risk Management WC	$1,239.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,689.80

OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]

Facility

$119.25

Service Code	CPT J2354
Hospital Charge Code	NDG91282
Hospital Revenue Code	636
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$89.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.55
Rate for Payer: Aetna of CA Government/Medicare	$71.55
Rate for Payer: Cash Price	$53.66
Rate for Payer: Health Smart Auto/Commercial	$71.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.55
Rate for Payer: LLUH Dept of Risk Management WC	$65.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.44

OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]

Facility

$119.25

Service Code	CPT J2354
Hospital Charge Code	NDG91282
Hospital Revenue Code	636
Min. Negotiated Rate	$65.59
Max. Negotiated Rate	$95.40
Rate for Payer: Cash Price	$53.66
Rate for Payer: Cigna of CA HMO/PPO	$95.40
Rate for Payer: Health Smart Auto/Commercial	$71.55
Rate for Payer: LLUH Dept of Risk Management WC	$65.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.44

OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]

Facility

$7.80

Service Code	CPT J2354
Hospital Charge Code	1720587
Hospital Revenue Code	636
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$5.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.68
Rate for Payer: Aetna of CA Government/Medicare	$4.68
Rate for Payer: Cash Price	$3.51
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.85

OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]

Facility

$7.80

Service Code	CPT J2354
Hospital Charge Code	1720587
Hospital Revenue Code	636
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$6.24
Rate for Payer: Cash Price	$3.51
Rate for Payer: Cigna of CA HMO/PPO	$6.24
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.85

OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]

Facility

$42.00

Service Code	CPT J2354
Hospital Charge Code	1720585
Hospital Revenue Code	636
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.78
Rate for Payer: Aetna of CA Government/Medicare	$7.74
Rate for Payer: Aetna of CA Government/Medicare	$25.20
Rate for Payer: Aetna of CA Government/Medicare	$35.78
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cash Price	$26.83
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: Health Smart Auto/Commercial	$7.74
Rate for Payer: Health Smart Auto/Commercial	$35.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$32.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.72

OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]

Facility

$59.63

Service Code	CPT J2354
Hospital Charge Code	1720585
Hospital Revenue Code	636
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$47.70
Rate for Payer: Cash Price	$26.83
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna of CA HMO/PPO	$33.60
Rate for Payer: Cigna of CA HMO/PPO	$47.70
Rate for Payer: Cigna of CA HMO/PPO	$10.32
Rate for Payer: Health Smart Auto/Commercial	$7.74
Rate for Payer: Health Smart Auto/Commercial	$35.78
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$7.10
Rate for Payer: LLUH Dept of Risk Management WC	$32.80
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.68

OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]

Facility

$5.40

Service Code	CPT J2354
Hospital Charge Code	1720586
Hospital Revenue Code	636
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$4.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.24
Rate for Payer: Aetna of CA Government/Medicare	$3.24
Rate for Payer: Cash Price	$2.43
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.05

OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]

Facility

$5.40

Service Code	CPT J2354
Hospital Charge Code	1720586
Hospital Revenue Code	636
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$4.32
Rate for Payer: Cash Price	$2.43
Rate for Payer: Cigna of CA HMO/PPO	$4.32
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.05

Know your out-of-pocket cost for care.

All Charges