Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION [36151]

Facility

$1,567.88

Service Code	CPT J2357
Hospital Charge Code	ERX36151
Hospital Revenue Code	636
Min. Negotiated Rate	$862.33
Max. Negotiated Rate	$1,254.30
Rate for Payer: Cash Price	$705.55
Rate for Payer: Cigna of CA HMO/PPO	$1,254.30
Rate for Payer: Health Smart Auto/Commercial	$940.73
Rate for Payer: LLUH Dept of Risk Management WC	$862.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,175.91

OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION [36151]

Facility

$1,567.88

Service Code	CPT J2357
Hospital Charge Code	ERX36151
Hospital Revenue Code	636
Min. Negotiated Rate	$862.33
Max. Negotiated Rate	$1,175.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$940.73
Rate for Payer: Aetna of CA Government/Medicare	$940.73
Rate for Payer: Cash Price	$705.55
Rate for Payer: Health Smart Auto/Commercial	$940.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$940.73
Rate for Payer: LLUH Dept of Risk Management WC	$862.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,175.91

OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE [223364]

Facility

$1,567.87

Service Code	CPT J2357
Hospital Charge Code	NDG223364
Hospital Revenue Code	636
Min. Negotiated Rate	$862.33
Max. Negotiated Rate	$1,254.30
Rate for Payer: Cash Price	$705.54
Rate for Payer: Cigna of CA HMO/PPO	$1,254.30
Rate for Payer: Health Smart Auto/Commercial	$940.72
Rate for Payer: LLUH Dept of Risk Management WC	$862.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,175.90

OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE [223364]

Facility

$1,567.87

Service Code	CPT J2357
Hospital Charge Code	NDG223364
Hospital Revenue Code	636
Min. Negotiated Rate	$862.33
Max. Negotiated Rate	$1,175.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$940.72
Rate for Payer: Aetna of CA Government/Medicare	$940.72
Rate for Payer: Cash Price	$705.54
Rate for Payer: Health Smart Auto/Commercial	$940.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$940.72
Rate for Payer: LLUH Dept of Risk Management WC	$862.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,175.90

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-65
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.92
Rate for Payer: Cash Price	$1.64
Rate for Payer: Cigna of CA HMO/PPO	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-11
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.19
Rate for Payer: Aetna of CA Government/Medicare	$2.19
Rate for Payer: Cash Price	$1.64
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.97

Service Code	NDC 60505-3170-7
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.73
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	$0.44
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	$0.73

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-11
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.92
Rate for Payer: Cash Price	$1.64
Rate for Payer: Cigna of CA HMO/PPO	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$3.65

Service Code	NDC 60687-127-65
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.19
Rate for Payer: Aetna of CA Government/Medicare	$2.19
Rate for Payer: Cash Price	$1.64
Rate for Payer: Health Smart Auto/Commercial	$2.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.74

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.27

Service Code	NDC 64380-761-11
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.97

Service Code	NDC 60505-3170-7
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.44
Rate for Payer: Cigna of CA HMO/PPO	$0.78
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	$0.73

OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]

Facility

$0.27

Service Code	NDC 64380-761-11
Hospital Charge Code	1712384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]

Facility

$0.08

Service Code	NDC 1191710202
Hospital Charge Code	1712604
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]

Facility

$0.08

Service Code	NDC 1191710202
Hospital Charge Code	1712604
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [31828]

Facility

$0.06

Service Code	NDC 1093933733
Hospital Charge Code	1712605
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

OMEGA-3 FATTY ACIDS 1,000 MG CAPSULE [31828]

Facility

$0.06

Service Code	NDC 1093933733
Hospital Charge Code	1712605
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]

Facility

$0.86

Service Code	NDC 37000-459-02
Hospital Charge Code	ERX36205
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]

Facility

$0.86

Service Code	NDC 37000-459-02
Hospital Charge Code	ERX36205
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]

Facility

$760.80

Service Code	CPT J0585
Hospital Charge Code	1721073
Hospital Revenue Code	636
Min. Negotiated Rate	$418.44
Max. Negotiated Rate	$608.64
Rate for Payer: Cash Price	$342.36
Rate for Payer: Cigna of CA HMO/PPO	$608.64
Rate for Payer: Health Smart Auto/Commercial	$456.48
Rate for Payer: LLUH Dept of Risk Management WC	$418.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$570.60

ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]

Facility

$760.80

Service Code	CPT J0585
Hospital Charge Code	1721073
Hospital Revenue Code	636
Min. Negotiated Rate	$418.44
Max. Negotiated Rate	$570.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$456.48
Rate for Payer: Aetna of CA Government/Medicare	$456.48
Rate for Payer: Cash Price	$342.36
Rate for Payer: Health Smart Auto/Commercial	$456.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$456.48
Rate for Payer: LLUH Dept of Risk Management WC	$418.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$570.60

ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]

Facility

$420.00

Service Code	NDC 0023-3919-50
Hospital Charge Code	ERX95794
Hospital Revenue Code	636
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$252.00
Rate for Payer: Aetna of CA Government/Medicare	$252.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Health Smart Auto/Commercial	$252.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$252.00
Rate for Payer: LLUH Dept of Risk Management WC	$231.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$315.00

ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]

Facility

$420.00

Service Code	NDC 0023-3919-50
Hospital Charge Code	ERX95794
Hospital Revenue Code	636
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$336.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna of CA HMO/PPO	$336.00
Rate for Payer: Health Smart Auto/Commercial	$252.00
Rate for Payer: LLUH Dept of Risk Management WC	$231.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$315.00

ONASEMNOGENE ABEPARVOVEC-XIOI 2 X 10EXP13 VG/ML IV SUSPENSION,KIT [224879]

Facility

$35,465.93

Service Code	CPT J3399
Hospital Charge Code	ERX224879
Hospital Revenue Code	636
Min. Negotiated Rate	$19,506.26
Max. Negotiated Rate	$28,372.74
Rate for Payer: Cash Price	$15,959.67
Rate for Payer: Cigna of CA HMO/PPO	$28,372.74
Rate for Payer: Health Smart Auto/Commercial	$21,279.56
Rate for Payer: LLUH Dept of Risk Management WC	$19,506.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26,599.45

ONASEMNOGENE ABEPARVOVEC-XIOI 2 X 10EXP13 VG/ML IV SUSPENSION,KIT [224879]

Facility

$35,465.93

Service Code	CPT J3399
Hospital Charge Code	ERX224879
Hospital Revenue Code	636
Min. Negotiated Rate	$19,506.26
Max. Negotiated Rate	$26,599.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21,279.56
Rate for Payer: Aetna of CA Government/Medicare	$21,279.56
Rate for Payer: Cash Price	$15,959.67
Rate for Payer: Health Smart Auto/Commercial	$21,279.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21,279.56
Rate for Payer: LLUH Dept of Risk Management WC	$19,506.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26,599.45

ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]

Facility

$0.83

Service Code	NDC 68001-246-17
Hospital Charge Code	1711782
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

Know your out-of-pocket cost for care.

All Charges