Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$27.68

Service Code	NDC 51672-4023-1
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$15.22
Max. Negotiated Rate	$20.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.61
Rate for Payer: Aetna of CA Government/Medicare	$16.61
Rate for Payer: Cash Price	$12.46
Rate for Payer: Health Smart Auto/Commercial	$16.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.61
Rate for Payer: LLUH Dept of Risk Management WC	$15.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.76

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$0.42

Service Code	NDC 70756-721-11
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
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: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$4.19

Service Code	NDC 68084-541-11
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.51
Rate for Payer: Aetna of CA Government/Medicare	$2.51
Rate for Payer: Cash Price	$1.89
Rate for Payer: Health Smart Auto/Commercial	$2.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.51
Rate for Payer: LLUH Dept of Risk Management WC	$2.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.14

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$0.42

Service Code	NDC 70756-721-11
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$4.19

Service Code	NDC 68084-541-01
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.51
Rate for Payer: Aetna of CA Government/Medicare	$2.51
Rate for Payer: Cash Price	$1.89
Rate for Payer: Health Smart Auto/Commercial	$2.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.51
Rate for Payer: LLUH Dept of Risk Management WC	$2.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.14

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$1.20

Service Code	NDC 0527-1050-01
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$0.42

Service Code	NDC 23155-288-01
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]

Facility

$47.64

Service Code	CPT J1120
Hospital Charge Code	1720067
Hospital Revenue Code	636
Min. Negotiated Rate	$26.20
Max. Negotiated Rate	$35.73
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	$22.68
Rate for Payer: Aetna of CA Government/Medicare	$22.68
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Aetna of CA Government/Medicare	$28.58
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.44
Rate for Payer: Cash Price	$17.01
Rate for Payer: Health Smart Auto/Commercial	$22.68
Rate for Payer: Health Smart Auto/Commercial	$28.58
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.68
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: LLUH Dept of Risk Management WC	$20.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.35

ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]

Facility

$37.80

Service Code	CPT J1120
Hospital Charge Code	1720067
Hospital Revenue Code	636
Min. Negotiated Rate	$20.79
Max. Negotiated Rate	$30.24
Rate for Payer: Cash Price	$17.01
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.44
Rate for Payer: Cigna of CA HMO/PPO	$30.24
Rate for Payer: Cigna of CA HMO/PPO	$38.40
Rate for Payer: Cigna of CA HMO/PPO	$38.11
Rate for Payer: Health Smart Auto/Commercial	$28.58
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$22.68
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 Beech St/Commercial/PHCS	$28.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.73

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.90

Service Code	NDC 42571-243-01
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.68

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.60

Service Code	NDC 50742-233-01
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
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: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 50268-042-11
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.98
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: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 50268-042-11
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.90

Service Code	NDC 42571-243-01
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
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	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$0.60

Service Code	NDC 50742-233-01
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.45

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 50268-042-12
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.98
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: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

$5.31

Service Code	NDC 50268-042-12
Hospital Charge Code	1710308
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.98

ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]

Facility

$2.77

Service Code	NDC 9994-0802-33
Hospital Charge Code	ERX4080233
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.08
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: Health Smart Auto/Commercial	$1.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.08

ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]

Facility

$2.77

Service Code	NDC 9994-0802-33
Hospital Charge Code	ERX4080233
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.22
Rate for Payer: Cash Price	$1.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.08

ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]

Facility

$0.01

Service Code	NDC 0264-2304-00
Hospital Charge Code	1770001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.01

ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]

Facility

$0.01

Service Code	NDC 0264-2304-00
Hospital Charge Code	1770001
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: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

ACETIC ACID 2 % EAR SOLUTION [17801]

Facility

$2.24

Service Code	NDC 52817-816-15
Hospital Charge Code	1740195
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna of CA HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.68

ACETIC ACID 2 % EAR SOLUTION [17801]

Facility

$2.24

Service Code	NDC 52817-816-15
Hospital Charge Code	1740195
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.68

ACETIC ACID (BULK) 3 % LIQUID [15091]

Facility

$0.04

Service Code	NDC 5155200516
Hospital Charge Code	NDG15091
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

ACETIC ACID (BULK) 3 % LIQUID [15091]

Facility

$0.04

Service Code	NDC 5155200516
Hospital Charge Code	NDG15091
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

Know your out-of-pocket cost for care.

All Charges