Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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: LLUH Dept of Risk Management WC	$20.37
Rate for Payer: Multiplan Commercial	$27.77

BRIVARACETAM 100 MG TABLET [214049]

Facility

$29.46

Service Code	NDC 50474-770-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$23.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.68
Rate for Payer: Aetna of CA Government/Medicare	$17.68
Rate for Payer: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.57
Rate for Payer: Health Smart Auto/Commercial	$17.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.68
Rate for Payer: LLUH Dept of Risk Management WC	$16.20
Rate for Payer: Multiplan Commercial	$22.09

BRIVARACETAM 100 MG TABLET [214049]

Facility

$29.46

Service Code	NDC 50474-770-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$23.57
Rate for Payer: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.57
Rate for Payer: Health Smart Auto/Commercial	$17.68
Rate for Payer: LLUH Dept of Risk Management WC	$16.20
Rate for Payer: Multiplan Commercial	$22.09

BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]

Facility

$5.89

Service Code	NDC 50474-870-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$4.71
Rate for Payer: Cash Price	$3.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.71
Rate for Payer: Health Smart Auto/Commercial	$3.53
Rate for Payer: LLUH Dept of Risk Management WC	$3.24
Rate for Payer: Multiplan Commercial	$4.42

BRIVARACETAM 10 MG/ML ORAL SOLUTION [214044]

Facility

$5.89

Service Code	NDC 50474-870-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$4.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.53
Rate for Payer: Aetna of CA Government/Medicare	$3.53
Rate for Payer: Cash Price	$3.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.71
Rate for Payer: Health Smart Auto/Commercial	$3.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.53
Rate for Payer: LLUH Dept of Risk Management WC	$3.24
Rate for Payer: Multiplan Commercial	$4.42

BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]

Facility

$15.15

Service Code	HCPCS C9399
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$12.12
Rate for Payer: Cash Price	$8.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.12
Rate for Payer: Health Smart Auto/Commercial	$9.09
Rate for Payer: LLUH Dept of Risk Management WC	$8.33
Rate for Payer: Multiplan Commercial	$11.36

BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION [214043]

Facility

$15.15

Service Code	HCPCS C9399
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$12.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.09
Rate for Payer: Aetna of CA Government/Medicare	$9.09
Rate for Payer: Cash Price	$8.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.12
Rate for Payer: Health Smart Auto/Commercial	$9.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.09
Rate for Payer: LLUH Dept of Risk Management WC	$8.33
Rate for Payer: Multiplan Commercial	$11.36

BRIVARACETAM 50 MG TABLET [214047]

Facility

$29.46

Service Code	NDC 50474-570-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$23.57
Rate for Payer: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.57
Rate for Payer: Health Smart Auto/Commercial	$17.68
Rate for Payer: LLUH Dept of Risk Management WC	$16.20
Rate for Payer: Multiplan Commercial	$22.09

BRIVARACETAM 50 MG TABLET [214047]

Facility

$29.46

Service Code	NDC 50474-570-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$23.57
Rate for Payer: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.57
Rate for Payer: Health Smart Auto/Commercial	$17.68
Rate for Payer: LLUH Dept of Risk Management WC	$16.20
Rate for Payer: Multiplan Commercial	$22.09

BRIVARACETAM 50 MG TABLET [214047]

Facility

$29.46

Service Code	NDC 50474-570-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$23.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.68
Rate for Payer: Aetna of CA Government/Medicare	$17.68
Rate for Payer: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.57
Rate for Payer: Health Smart Auto/Commercial	$17.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.68
Rate for Payer: LLUH Dept of Risk Management WC	$16.20
Rate for Payer: Multiplan Commercial	$22.09

BRIVARACETAM 50 MG TABLET [214047]

Facility

$29.46

Service Code	NDC 50474-570-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$23.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.68
Rate for Payer: Aetna of CA Government/Medicare	$17.68
Rate for Payer: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.57
Rate for Payer: Health Smart Auto/Commercial	$17.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.68
Rate for Payer: LLUH Dept of Risk Management WC	$16.20
Rate for Payer: Multiplan Commercial	$22.09

BROMFENAC 0.09 % EYE DROPS [41146]

Facility

$100.56

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$55.31
Max. Negotiated Rate	$80.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.34
Rate for Payer: Aetna of CA Government/Medicare	$60.34
Rate for Payer: Cash Price	$55.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.45
Rate for Payer: Health Smart Auto/Commercial	$60.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.34
Rate for Payer: LLUH Dept of Risk Management WC	$55.31
Rate for Payer: Multiplan Commercial	$75.42

BROMFENAC 0.09 % EYE DROPS [41146]

Facility

$100.56

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$55.31
Max. Negotiated Rate	$80.45
Rate for Payer: Cash Price	$55.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.45
Rate for Payer: Health Smart Auto/Commercial	$60.34
Rate for Payer: LLUH Dept of Risk Management WC	$55.31
Rate for Payer: Multiplan Commercial	$75.42

BROMOCRIPTINE 2.5 MG TABLET [9297]

Facility

$3.97

Service Code	NDC 0574-0106-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

BROMOCRIPTINE 2.5 MG TABLET [9297]

Facility

$3.97

Service Code	NDC 0574-0106-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

BROMOCRIPTINE 2.5 MG TABLET [9297]

Facility

$3.97

Service Code	NDC 63304-962-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

BROMOCRIPTINE 2.5 MG TABLET [9297]

Facility

$6.02

Service Code	NDC 0781-5325-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.31
Rate for Payer: Multiplan Commercial	$4.51

BROMOCRIPTINE 2.5 MG TABLET [9297]

Facility

$6.02

Service Code	NDC 0781-5325-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.61
Rate for Payer: Aetna of CA Government/Medicare	$3.61
Rate for Payer: Cash Price	$3.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.31
Rate for Payer: Multiplan Commercial	$4.51

BROMOCRIPTINE 2.5 MG TABLET [9297]

Facility

$3.97

Service Code	NDC 63304-962-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.98

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$1.10

Service Code	NDC 69097-318-87
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Cash Price	$0.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Commercial	$0.83

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$4.52

Service Code	NDC 0093-6815-73
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.71
Rate for Payer: Aetna of CA Government/Medicare	$2.71
Rate for Payer: Cash Price	$2.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.62
Rate for Payer: Health Smart Auto/Commercial	$2.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.71
Rate for Payer: LLUH Dept of Risk Management WC	$2.49
Rate for Payer: Multiplan Commercial	$3.39

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$1.10

Service Code	NDC 69097-318-87
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.66
Rate for Payer: Aetna of CA Government/Medicare	$0.66
Rate for Payer: Cash Price	$0.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Commercial	$0.83

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$20.40

Service Code	NDC 0487-9601-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$16.32
Rate for Payer: Cash Price	$11.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.32
Rate for Payer: Health Smart Auto/Commercial	$12.24
Rate for Payer: LLUH Dept of Risk Management WC	$11.22
Rate for Payer: Multiplan Commercial	$15.30

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$4.52

Service Code	NDC 0093-6815-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.71
Rate for Payer: Aetna of CA Government/Medicare	$2.71
Rate for Payer: Cash Price	$2.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.62
Rate for Payer: Health Smart Auto/Commercial	$2.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.71
Rate for Payer: LLUH Dept of Risk Management WC	$2.49
Rate for Payer: Multiplan Commercial	$3.39

BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [28774]

Facility

$20.40

Service Code	NDC 0487-9601-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$16.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.24
Rate for Payer: Aetna of CA Government/Medicare	$12.24
Rate for Payer: Cash Price	$11.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.32
Rate for Payer: Health Smart Auto/Commercial	$12.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.24
Rate for Payer: LLUH Dept of Risk Management WC	$11.22
Rate for Payer: Multiplan Commercial	$15.30

Know your out-of-pocket cost for care.

All Charges