Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$1.56

Service Code	NDC 60687-679-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]

Facility

$84.00

Service Code	HCPCS J0583
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.80
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$64.80
Rate for Payer: Cash Price	$46.20
Rate for Payer: Cash Price	$59.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00
Rate for Payer: Multiplan Commercial	$81.00

BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]

Facility

$108.00

Service Code	HCPCS J0583
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$86.40
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cash Price	$46.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$81.00
Rate for Payer: Multiplan Commercial	$63.00

BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]

Facility

$60.55

Service Code	HCPCS J9040
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$48.44
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$21.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.44
Rate for Payer: Health Smart Auto/Commercial	$23.84
Rate for Payer: Health Smart Auto/Commercial	$36.33
Rate for Payer: LLUH Dept of Risk Management WC	$33.30
Rate for Payer: LLUH Dept of Risk Management WC	$21.86
Rate for Payer: Multiplan Commercial	$29.80
Rate for Payer: Multiplan Commercial	$45.41

BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]

Facility

$60.55

Service Code	HCPCS J9040
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$48.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.84
Rate for Payer: Aetna of CA Government/Medicare	$36.33
Rate for Payer: Aetna of CA Government/Medicare	$23.84
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$21.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.79
Rate for Payer: Health Smart Auto/Commercial	$23.84
Rate for Payer: Health Smart Auto/Commercial	$36.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.33
Rate for Payer: LLUH Dept of Risk Management WC	$33.30
Rate for Payer: LLUH Dept of Risk Management WC	$21.86
Rate for Payer: Multiplan Commercial	$45.41
Rate for Payer: Multiplan Commercial	$29.80

BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]

Facility

$112.34

Service Code	HCPCS J9040
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$61.79
Max. Negotiated Rate	$89.87
Rate for Payer: Cash Price	$61.79
Rate for Payer: Cash Price	$44.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.87
Rate for Payer: Health Smart Auto/Commercial	$67.40
Rate for Payer: Health Smart Auto/Commercial	$48.02
Rate for Payer: LLUH Dept of Risk Management WC	$61.79
Rate for Payer: LLUH Dept of Risk Management WC	$44.02
Rate for Payer: Multiplan Commercial	$60.02
Rate for Payer: Multiplan Commercial	$84.25

BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]

Facility

$80.03

Service Code	HCPCS J9040
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.02
Max. Negotiated Rate	$64.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.40
Rate for Payer: Aetna of CA Government/Medicare	$48.02
Rate for Payer: Aetna of CA Government/Medicare	$67.40
Rate for Payer: Cash Price	$61.79
Rate for Payer: Cash Price	$44.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.02
Rate for Payer: Health Smart Auto/Commercial	$48.02
Rate for Payer: Health Smart Auto/Commercial	$67.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.40
Rate for Payer: LLUH Dept of Risk Management WC	$61.79
Rate for Payer: LLUH Dept of Risk Management WC	$44.02
Rate for Payer: Multiplan Commercial	$84.25
Rate for Payer: Multiplan Commercial	$60.02

BORIC ACID (BULK) POWDER [1131]

Facility

$0.94

Service Code	NDC 3877900648
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

BORIC ACID (BULK) POWDER [1131]

Facility

$0.94

Service Code	NDC 3877900649
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

BORIC ACID (BULK) POWDER [1131]

Facility

$0.94

Service Code	NDC 3877900649
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

BORIC ACID (BULK) POWDER [1131]

Facility

$0.94

Service Code	NDC 3877900648
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$240.00

Service Code	HCPCS J9041
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$192.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$165.00
Rate for Payer: Cash Price	$27.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$192.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$240.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Health Smart Auto/Commercial	$180.00
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: LLUH Dept of Risk Management WC	$165.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: Multiplan Commercial	$180.00
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$225.00

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$300.00

Service Code	HCPCS J9041
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$180.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$144.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.24
Rate for Payer: Aetna of CA Government/Medicare	$144.00
Rate for Payer: Aetna of CA Government/Medicare	$30.24
Rate for Payer: Aetna of CA Government/Medicare	$180.00
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$165.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$192.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$240.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: Health Smart Auto/Commercial	$180.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$144.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$180.00
Rate for Payer: LLUH Dept of Risk Management WC	$165.00
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: Multiplan Commercial	$180.00
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$225.00

BOSENTAN 125 MG TABLET [31876]

Facility

$17.45

Service Code	NDC 68382-447-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.96
Rate for Payer: Cash Price	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.96
Rate for Payer: Health Smart Auto/Commercial	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$9.60
Rate for Payer: Multiplan Commercial	$13.09

BOSENTAN 125 MG TABLET [31876]

Facility

$17.45

Service Code	NDC 68382-447-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.47
Rate for Payer: Aetna of CA Government/Medicare	$10.47
Rate for Payer: Cash Price	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.96
Rate for Payer: Health Smart Auto/Commercial	$10.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$9.60
Rate for Payer: Multiplan Commercial	$13.09

BOSENTAN 31.25 MG 1/2 TABLET [4081538]

Facility

$17.45

Service Code	NDC 68382-446-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.96
Rate for Payer: Cash Price	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.96
Rate for Payer: Health Smart Auto/Commercial	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$9.60
Rate for Payer: Multiplan Commercial	$13.09

BOSENTAN 31.25 MG 1/2 TABLET [4081538]

Facility

$17.45

Service Code	NDC 68382-446-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.47
Rate for Payer: Aetna of CA Government/Medicare	$10.47
Rate for Payer: Cash Price	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.96
Rate for Payer: Health Smart Auto/Commercial	$10.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$9.60
Rate for Payer: Multiplan Commercial	$13.09

BOSENTAN 62.5 MG TABLET [31875]

Facility

$17.45

Service Code	NDC 68382-446-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.47
Rate for Payer: Aetna of CA Government/Medicare	$10.47
Rate for Payer: Cash Price	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.96
Rate for Payer: Health Smart Auto/Commercial	$10.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$9.60
Rate for Payer: Multiplan Commercial	$13.09

BOSENTAN 62.5 MG TABLET [31875]

Facility

$268.28

Service Code	NDC 66215-101-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$147.55
Max. Negotiated Rate	$214.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.97
Rate for Payer: Aetna of CA Government/Medicare	$160.97
Rate for Payer: Cash Price	$147.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.62
Rate for Payer: Health Smart Auto/Commercial	$160.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.97
Rate for Payer: LLUH Dept of Risk Management WC	$147.55
Rate for Payer: Multiplan Commercial	$201.21

BOSENTAN 62.5 MG TABLET [31875]

Facility

$268.28

Service Code	NDC 66215-101-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$147.55
Max. Negotiated Rate	$214.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.97
Rate for Payer: Aetna of CA Government/Medicare	$160.97
Rate for Payer: Cash Price	$147.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.62
Rate for Payer: Health Smart Auto/Commercial	$160.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.97
Rate for Payer: LLUH Dept of Risk Management WC	$147.55
Rate for Payer: Multiplan Commercial	$201.21

BOSENTAN 62.5 MG TABLET [31875]

Facility

$268.28

Service Code	NDC 66215-101-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$147.55
Max. Negotiated Rate	$214.62
Rate for Payer: Cash Price	$147.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.62
Rate for Payer: Health Smart Auto/Commercial	$160.97
Rate for Payer: LLUH Dept of Risk Management WC	$147.55
Rate for Payer: Multiplan Commercial	$201.21

BOSENTAN 62.5 MG TABLET [31875]

Facility

$268.28

Service Code	NDC 66215-101-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$147.55
Max. Negotiated Rate	$214.62
Rate for Payer: Cash Price	$147.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.62
Rate for Payer: Health Smart Auto/Commercial	$160.97
Rate for Payer: LLUH Dept of Risk Management WC	$147.55
Rate for Payer: Multiplan Commercial	$201.21

BOSENTAN 62.5 MG TABLET [31875]

Facility

$17.45

Service Code	NDC 68382-446-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.96
Rate for Payer: Cash Price	$9.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.96
Rate for Payer: Health Smart Auto/Commercial	$10.47
Rate for Payer: LLUH Dept of Risk Management WC	$9.60
Rate for Payer: Multiplan Commercial	$13.09

BOSENTAN CRUSHED TABLET IN WATER [40831875]

Facility

$268.28

Service Code	NDC 66215-101-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$147.55
Max. Negotiated Rate	$214.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.97
Rate for Payer: Aetna of CA Government/Medicare	$160.97
Rate for Payer: Cash Price	$147.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.62
Rate for Payer: Health Smart Auto/Commercial	$160.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.97
Rate for Payer: LLUH Dept of Risk Management WC	$147.55
Rate for Payer: Multiplan Commercial	$201.21

BOSENTAN CRUSHED TABLET IN WATER [40831875]

Facility

$268.28

Service Code	NDC 66215-101-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$147.55
Max. Negotiated Rate	$214.62
Rate for Payer: Cash Price	$147.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.62
Rate for Payer: Health Smart Auto/Commercial	$160.97
Rate for Payer: LLUH Dept of Risk Management WC	$147.55
Rate for Payer: Multiplan Commercial	$201.21

Know your out-of-pocket cost for care.

All Charges