Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]

Facility

$0.08

Service Code	NDC 0904579146
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.06

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$1.12

Service Code	NDC 5167221142
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$1.12

Service Code	NDC 5167221140
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$1.12

Service Code	NDC 5167221140
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$1.12

Service Code	NDC 5167221142
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$3.22

Service Code	NDC 5026805411
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$0.42

Service Code	NDC 7075672111
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$3.22

Service Code	NDC 5026805411
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.93
Rate for Payer: Aetna of CA Government/Medicare	$1.93
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$3.22

Service Code	NDC 5026805415
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$0.42

Service Code	NDC 7075672111
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$3.22

Service Code	NDC 5026805415
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.93
Rate for Payer: Aetna of CA Government/Medicare	$1.93
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]

Facility

$47.64

Service Code	HCPCS J1120
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$26.20
Max. Negotiated Rate	$38.11
Rate for Payer: Cash Price	$21.44
Rate for Payer: Cash Price	$17.01
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$23.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.20
Rate for Payer: Health Smart Auto/Commercial	$31.65
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$22.68
Rate for Payer: Health Smart Auto/Commercial	$28.58
Rate for Payer: LLUH Dept of Risk Management WC	$20.79
Rate for Payer: LLUH Dept of Risk Management WC	$26.20
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$29.01
Rate for Payer: Multiplan Commercial	$35.73
Rate for Payer: Multiplan Commercial	$28.35
Rate for Payer: Multiplan Commercial	$39.56
Rate for Payer: Multiplan Commercial	$36.00

ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]

Facility

$37.80

Service Code	HCPCS J1120
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$20.79
Max. Negotiated Rate	$30.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.65
Rate for Payer: Aetna of CA Government/Medicare	$31.65
Rate for Payer: Aetna of CA Government/Medicare	$28.58
Rate for Payer: Aetna of CA Government/Medicare	$22.68
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Cash Price	$17.01
Rate for Payer: Cash Price	$23.74
Rate for Payer: Cash Price	$21.44
Rate for Payer: Cash Price	$21.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.20
Rate for Payer: Health Smart Auto/Commercial	$31.65
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$28.58
Rate for Payer: Health Smart Auto/Commercial	$22.68
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$31.65
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$28.58
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$22.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.01
Rate for Payer: LLUH Dept of Risk Management WC	$20.79
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.20
Rate for Payer: Multiplan Commercial	$35.73
Rate for Payer: Multiplan Commercial	$36.00
Rate for Payer: Multiplan Commercial	$39.56
Rate for Payer: Multiplan Commercial	$28.35

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.60

Service Code	NDC 5074223301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.90

Service Code	NDC 4257124301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.90

Service Code	NDC 4257124301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.60

Service Code	NDC 5074223301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 5026804212
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 5026804211
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 5026804212
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 5026804211
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]

Facility

$2.77

Service Code	NDC 9994080233
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.66
Rate for Payer: Aetna of CA Government/Medicare	$1.66
Rate for Payer: Cash Price	$1.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.22
Rate for Payer: Health Smart Auto/Commercial	$1.66
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$2.08

ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]

Facility

$2.77

Service Code	NDC 9994080233
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.22
Rate for Payer: Cash Price	$1.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.22
Rate for Payer: Health Smart Auto/Commercial	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$2.08

ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]

Facility

$0.01

Service Code	NDC 0264230400
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]

Facility

$0.01

Service Code	NDC 0264230400
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

Know your out-of-pocket cost for care.

All Charges