Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION [108055]

Facility

$376.67

Service Code	CPT J9303
Hospital Charge Code	1755745
Hospital Revenue Code	636
Min. Negotiated Rate	$207.17
Max. Negotiated Rate	$301.34
Rate for Payer: Cash Price	$169.50
Rate for Payer: Cigna of CA HMO/PPO	$301.34
Rate for Payer: Health Smart Auto/Commercial	$226.00
Rate for Payer: LLUH Dept of Risk Management WC	$207.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$282.50

PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION [108055]

Facility

$376.67

Service Code	CPT J9303
Hospital Charge Code	1755745
Hospital Revenue Code	636
Min. Negotiated Rate	$207.17
Max. Negotiated Rate	$282.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$226.00
Rate for Payer: Aetna of CA Government/Medicare	$226.00
Rate for Payer: Cash Price	$169.50
Rate for Payer: Health Smart Auto/Commercial	$226.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$226.00
Rate for Payer: LLUH Dept of Risk Management WC	$207.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$282.50

PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [108057]

Facility

$376.67

Service Code	CPT J9303
Hospital Charge Code	1755726
Hospital Revenue Code	636
Min. Negotiated Rate	$207.17
Max. Negotiated Rate	$301.34
Rate for Payer: Cash Price	$169.50
Rate for Payer: Cigna of CA HMO/PPO	$301.34
Rate for Payer: Health Smart Auto/Commercial	$226.00
Rate for Payer: LLUH Dept of Risk Management WC	$207.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$282.50

PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [108057]

Facility

$376.67

Service Code	CPT J9303
Hospital Charge Code	1755726
Hospital Revenue Code	636
Min. Negotiated Rate	$207.17
Max. Negotiated Rate	$282.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$226.00
Rate for Payer: Aetna of CA Government/Medicare	$226.00
Rate for Payer: Cash Price	$169.50
Rate for Payer: Health Smart Auto/Commercial	$226.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$226.00
Rate for Payer: LLUH Dept of Risk Management WC	$207.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$282.50

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 31722-712-90
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-11
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-01
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 65862-559-90
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-11
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 31722-712-90
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.33

Service Code	NDC 50268-636-15
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 0378-6688-77
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.30

Service Code	NDC 68084-643-01
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.24

Service Code	NDC 13668-096-90
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.24

Service Code	NDC 13668-096-90
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 0378-6688-77
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.13

Service Code	NDC 65862-559-90
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]

Facility

$0.33

Service Code	NDC 50268-636-15
Hospital Charge Code	1712608
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]

Facility

$12.00

Service Code	CPT C9113
Hospital Charge Code	1759991
Hospital Revenue Code	636
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$3.52
Rate for Payer: Aetna of CA Government/Medicare	$3.53
Rate for Payer: Cash Price	$2.65
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Smart Auto/Commercial	$3.53
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$3.52
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.53
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.23
Rate for Payer: LLUH Dept of Risk Management WC	$3.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.40

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]

Facility

$12.00

Service Code	CPT C9113
Hospital Charge Code	1759991
Hospital Revenue Code	636
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cigna of CA HMO/PPO	$9.60
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Cigna of CA HMO/PPO	$4.70
Rate for Payer: Health Smart Auto/Commercial	$3.53
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$3.52
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cash Price	$2.65
Rate for Payer: Cigna of CA HMO/PPO	$4.69
Rate for Payer: LLUH Dept of Risk Management WC	$3.22
Rate for Payer: LLUH Dept of Risk Management WC	$3.23
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.26

Service Code	NDC 50268-639-15
Hospital Charge Code	1712267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
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	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.34

Service Code	NDC 51079-051-20
Hospital Charge Code	1712267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.34

Service Code	NDC 51079-051-01
Hospital Charge Code	1712267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.21

Service Code	NDC 68084-813-11
Hospital Charge Code	1712267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]

Facility

$0.34

Service Code	NDC 51079-051-01
Hospital Charge Code	1712267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

Know your out-of-pocket cost for care.

All Charges