Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BOSENTAN CRUSHED TABLET IN WATER [40831875]

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 CRUSHED TABLET IN WATER [40831875]

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 ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]

Facility

$16.44

Service Code	NDC 9940-8318-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$13.15
Rate for Payer: Cash Price	$9.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.15
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Commercial	$12.33

BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]

Facility

$16.44

Service Code	NDC 9940-8318-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$13.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.86
Rate for Payer: Aetna of CA Government/Medicare	$9.86
Rate for Payer: Cash Price	$9.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.15
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Commercial	$12.33

BOSUTINIB 100 MG TABLET [197246]

Facility

$214.96

Service Code	NDC 0069-0135-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$118.23
Max. Negotiated Rate	$171.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$128.98
Rate for Payer: Aetna of CA Government/Medicare	$128.98
Rate for Payer: Cash Price	$118.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$171.97
Rate for Payer: Health Smart Auto/Commercial	$128.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$128.98
Rate for Payer: LLUH Dept of Risk Management WC	$118.23
Rate for Payer: Multiplan Commercial	$161.22

BOSUTINIB 100 MG TABLET [197246]

Facility

$214.96

Service Code	NDC 0069-0135-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$118.23
Max. Negotiated Rate	$171.97
Rate for Payer: Cash Price	$118.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$171.97
Rate for Payer: Health Smart Auto/Commercial	$128.98
Rate for Payer: LLUH Dept of Risk Management WC	$118.23
Rate for Payer: Multiplan Commercial	$161.22

BOSUTINIB 400 MG TABLET [220449]

Facility

$859.83

Service Code	NDC 0069-0193-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$472.91
Max. Negotiated Rate	$687.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$515.90
Rate for Payer: Aetna of CA Government/Medicare	$515.90
Rate for Payer: Cash Price	$472.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$687.86
Rate for Payer: Health Smart Auto/Commercial	$515.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$515.90
Rate for Payer: LLUH Dept of Risk Management WC	$472.91
Rate for Payer: Multiplan Commercial	$644.87

BOSUTINIB 400 MG TABLET [220449]

Facility

$859.83

Service Code	NDC 0069-0193-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$472.91
Max. Negotiated Rate	$687.86
Rate for Payer: Cash Price	$472.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$687.86
Rate for Payer: Health Smart Auto/Commercial	$515.90
Rate for Payer: LLUH Dept of Risk Management WC	$472.91
Rate for Payer: Multiplan Commercial	$644.87

BOSUTINIB 500 MG TABLET [197247]

Facility

$859.83

Service Code	NDC 0069-0136-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$472.91
Max. Negotiated Rate	$687.86
Rate for Payer: Cash Price	$472.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$687.86
Rate for Payer: Health Smart Auto/Commercial	$515.90
Rate for Payer: LLUH Dept of Risk Management WC	$472.91
Rate for Payer: Multiplan Commercial	$644.87

BOSUTINIB 500 MG TABLET [197247]

Facility

$859.83

Service Code	NDC 0069-0136-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$472.91
Max. Negotiated Rate	$687.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$515.90
Rate for Payer: Aetna of CA Government/Medicare	$515.90
Rate for Payer: Cash Price	$472.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$687.86
Rate for Payer: Health Smart Auto/Commercial	$515.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$515.90
Rate for Payer: LLUH Dept of Risk Management WC	$472.91
Rate for Payer: Multiplan Commercial	$644.87

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$36.80

Service Code	NDC 61314-144-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$29.44
Rate for Payer: Cash Price	$20.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.44
Rate for Payer: Health Smart Auto/Commercial	$22.08
Rate for Payer: LLUH Dept of Risk Management WC	$20.24
Rate for Payer: Multiplan Commercial	$27.60

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$36.80

Service Code	NDC 61314-144-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$29.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.08
Rate for Payer: Aetna of CA Government/Medicare	$22.08
Rate for Payer: Cash Price	$20.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.44
Rate for Payer: Health Smart Auto/Commercial	$22.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.08
Rate for Payer: LLUH Dept of Risk Management WC	$20.24
Rate for Payer: Multiplan Commercial	$27.60

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$49.75

Service Code	NDC 0023-9177-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$39.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.85
Rate for Payer: Aetna of CA Government/Medicare	$29.85
Rate for Payer: Cash Price	$27.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.80
Rate for Payer: Health Smart Auto/Commercial	$29.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.85
Rate for Payer: LLUH Dept of Risk Management WC	$27.36
Rate for Payer: Multiplan Commercial	$37.31

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$49.75

Service Code	NDC 0023-9177-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$39.80
Rate for Payer: Cash Price	$27.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.80
Rate for Payer: Health Smart Auto/Commercial	$29.85
Rate for Payer: LLUH Dept of Risk Management WC	$27.36
Rate for Payer: Multiplan Commercial	$37.31

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$1.47

Service Code	NDC 70069-231-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Commercial	$1.10

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$1.47

Service Code	NDC 70069-231-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Commercial	$1.10

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$48.99

Service Code	NDC 0023-9211-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$26.94
Max. Negotiated Rate	$39.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.39
Rate for Payer: Aetna of CA Government/Medicare	$29.39
Rate for Payer: Cash Price	$26.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.19
Rate for Payer: Health Smart Auto/Commercial	$29.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.39
Rate for Payer: LLUH Dept of Risk Management WC	$26.94
Rate for Payer: Multiplan Commercial	$36.74

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$30.72

Service Code	NDC 0832-1425-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.90
Max. Negotiated Rate	$24.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.43
Rate for Payer: Aetna of CA Government/Medicare	$18.43
Rate for Payer: Cash Price	$16.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.58
Rate for Payer: Health Smart Auto/Commercial	$18.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.43
Rate for Payer: LLUH Dept of Risk Management WC	$16.90
Rate for Payer: Multiplan Commercial	$23.04

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$30.72

Service Code	NDC 0832-1425-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.90
Max. Negotiated Rate	$24.58
Rate for Payer: Cash Price	$16.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.58
Rate for Payer: Health Smart Auto/Commercial	$18.43
Rate for Payer: LLUH Dept of Risk Management WC	$16.90
Rate for Payer: Multiplan Commercial	$23.04

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$19.97

Service Code	NDC 82182-455-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$15.98
Rate for Payer: Cash Price	$10.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.98
Rate for Payer: Health Smart Auto/Commercial	$11.98
Rate for Payer: LLUH Dept of Risk Management WC	$10.98
Rate for Payer: Multiplan Commercial	$14.98

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$19.97

Service Code	NDC 82182-455-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$15.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.98
Rate for Payer: Aetna of CA Government/Medicare	$11.98
Rate for Payer: Cash Price	$10.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.98
Rate for Payer: Health Smart Auto/Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.98
Rate for Payer: LLUH Dept of Risk Management WC	$10.98
Rate for Payer: Multiplan Commercial	$14.98

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$48.99

Service Code	NDC 0023-9211-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$26.94
Max. Negotiated Rate	$39.19
Rate for Payer: Cash Price	$26.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.19
Rate for Payer: Health Smart Auto/Commercial	$29.39
Rate for Payer: LLUH Dept of Risk Management WC	$26.94
Rate for Payer: Multiplan Commercial	$36.74

BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]

Facility

$35.14

Service Code	NDC 0781-6014-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.33
Max. Negotiated Rate	$28.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.08
Rate for Payer: Aetna of CA Government/Medicare	$21.08
Rate for Payer: Cash Price	$19.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.11
Rate for Payer: Health Smart Auto/Commercial	$21.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.08
Rate for Payer: LLUH Dept of Risk Management WC	$19.33
Rate for Payer: Multiplan Commercial	$26.36

BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]

Facility

$37.03

Service Code	NDC 68682-464-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$20.37
Max. Negotiated Rate	$29.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.22
Rate for Payer: Aetna of CA Government/Medicare	$22.22
Rate for Payer: Cash Price	$20.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.62
Rate for Payer: Health Smart Auto/Commercial	$22.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.22
Rate for Payer: LLUH Dept of Risk Management WC	$20.37
Rate for Payer: Multiplan Commercial	$27.77

BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION [22953]

Facility

$35.14

Service Code	NDC 0781-6014-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.33
Max. Negotiated Rate	$28.11
Rate for Payer: Cash Price	$19.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.11
Rate for Payer: Health Smart Auto/Commercial	$21.08
Rate for Payer: LLUH Dept of Risk Management WC	$19.33
Rate for Payer: Multiplan Commercial	$26.36

Know your out-of-pocket cost for care.

All Charges