Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]

Facility

$0.02

Service Code	NDC 46122-639-34
Hospital Charge Code	NDG112159A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
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	$0.02

BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]

Facility

$0.04

Service Code	NDC 149003930
Hospital Charge Code	NDG112159
Hospital Revenue Code	259
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

BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]

Facility

$0.02

Service Code	NDC 46122-639-34
Hospital Charge Code	NDG112159A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
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: Cash Price	$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	$0.02

BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]

Facility

$0.01

Service Code	NDC 0536-1287-36
Hospital Charge Code	NDG112159A
Hospital Revenue Code	259
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

BISMUTH SUBSALICYLATE 525 MG/15 ML ORAL SUSPENSION [112159]

Facility

$0.04

Service Code	NDC 149003930
Hospital Charge Code	NDG112159
Hospital Revenue Code	259
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

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 52817-270-30
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$1.56

Service Code	NDC 60687-679-11
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 29300-126-01
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 52817-270-10
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 29300-126-13
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 52817-270-10
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$1.56

Service Code	NDC 60687-679-11
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.17
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	$0.70
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 Beech St/Commercial/PHCS	$1.17

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 29300-126-01
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 29300-126-13
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BISOPROLOL FUMARATE 5 MG TABLET [18288]

Facility

$0.69

Service Code	NDC 52817-270-30
Hospital Charge Code	ERX18288
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]

Facility

$174.00

Service Code	CPT J0583
Hospital Charge Code	1722040
Hospital Revenue Code	636
Min. Negotiated Rate	$95.70
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$104.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.54
Rate for Payer: Aetna of CA Government/Medicare	$104.40
Rate for Payer: Aetna of CA Government/Medicare	$51.54
Rate for Payer: Cash Price	$38.66
Rate for Payer: Cash Price	$78.30
Rate for Payer: Health Smart Auto/Commercial	$51.54
Rate for Payer: Health Smart Auto/Commercial	$104.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$104.40
Rate for Payer: LLUH Dept of Risk Management WC	$95.70
Rate for Payer: LLUH Dept of Risk Management WC	$47.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$130.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.42

BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [29396]

Facility

$85.90

Service Code	CPT J0583
Hospital Charge Code	1722040
Hospital Revenue Code	636
Min. Negotiated Rate	$47.24
Max. Negotiated Rate	$68.72
Rate for Payer: Cash Price	$38.66
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna of CA HMO/PPO	$139.20
Rate for Payer: Cigna of CA HMO/PPO	$68.72
Rate for Payer: Health Smart Auto/Commercial	$51.54
Rate for Payer: Health Smart Auto/Commercial	$104.40
Rate for Payer: LLUH Dept of Risk Management WC	$47.24
Rate for Payer: LLUH Dept of Risk Management WC	$95.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$130.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.42

BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]

Facility

$39.74

Service Code	CPT J9040
Hospital Charge Code	ERX9289
Hospital Revenue Code	636
Min. Negotiated Rate	$21.86
Max. Negotiated Rate	$31.79
Rate for Payer: Cash Price	$17.88
Rate for Payer: Cash Price	$27.25
Rate for Payer: Cash Price	$30.89
Rate for Payer: Cigna of CA HMO/PPO	$54.91
Rate for Payer: Cigna of CA HMO/PPO	$48.44
Rate for Payer: Cigna of CA HMO/PPO	$31.79
Rate for Payer: Health Smart Auto/Commercial	$23.84
Rate for Payer: Health Smart Auto/Commercial	$41.18
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	$37.75
Rate for Payer: LLUH Dept of Risk Management WC	$21.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.41

BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]

Facility

$68.64

Service Code	CPT J9040
Hospital Charge Code	ERX9289
Hospital Revenue Code	636
Min. Negotiated Rate	$37.75
Max. Negotiated Rate	$51.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.33
Rate for Payer: Aetna of CA Government/Medicare	$36.33
Rate for Payer: Aetna of CA Government/Medicare	$23.84
Rate for Payer: Aetna of CA Government/Medicare	$41.18
Rate for Payer: Cash Price	$17.88
Rate for Payer: Cash Price	$27.25
Rate for Payer: Cash Price	$30.89
Rate for Payer: Health Smart Auto/Commercial	$41.18
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	$41.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.84
Rate for Payer: LLUH Dept of Risk Management WC	$21.86
Rate for Payer: LLUH Dept of Risk Management WC	$33.30
Rate for Payer: LLUH Dept of Risk Management WC	$37.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.48

BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]

Facility

$127.32

Service Code	CPT J9040
Hospital Charge Code	ERX17012
Hospital Revenue Code	636
Min. Negotiated Rate	$70.03
Max. Negotiated Rate	$101.86
Rate for Payer: Cash Price	$57.29
Rate for Payer: Cash Price	$50.55
Rate for Payer: Cash Price	$36.01
Rate for Payer: Cigna of CA HMO/PPO	$89.87
Rate for Payer: Cigna of CA HMO/PPO	$101.86
Rate for Payer: Cigna of CA HMO/PPO	$64.02
Rate for Payer: Health Smart Auto/Commercial	$76.39
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: LLUH Dept of Risk Management WC	$70.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$95.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$84.26

BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION [17012]

Facility

$112.34

Service Code	CPT J9040
Hospital Charge Code	ERX17012
Hospital Revenue Code	636
Min. Negotiated Rate	$61.79
Max. Negotiated Rate	$84.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$76.39
Rate for Payer: Aetna of CA Government/Medicare	$67.40
Rate for Payer: Aetna of CA Government/Medicare	$48.02
Rate for Payer: Aetna of CA Government/Medicare	$76.39
Rate for Payer: Cash Price	$50.55
Rate for Payer: Cash Price	$36.01
Rate for Payer: Cash Price	$57.29
Rate for Payer: Health Smart Auto/Commercial	$48.02
Rate for Payer: Health Smart Auto/Commercial	$76.39
Rate for Payer: Health Smart Auto/Commercial	$67.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$76.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.02
Rate for Payer: LLUH Dept of Risk Management WC	$70.03
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 Beech St/Commercial/PHCS	$84.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$95.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.02

BORIC ACID (BULK) POWDER [1131]

Facility

$0.95

Service Code	NDC 3877900649
Hospital Charge Code	NDG1131
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.57
Rate for Payer: Aetna of CA Government/Medicare	$0.57
Rate for Payer: Cash Price	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

BORIC ACID (BULK) POWDER [1131]

Facility

$0.95

Service Code	NDC 3877900648
Hospital Charge Code	NDG1131A
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.43
Rate for Payer: Cigna of CA HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

BORIC ACID (BULK) POWDER [1131]

Facility

$0.95

Service Code	NDC 3877900649
Hospital Charge Code	NDG1131
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.43
Rate for Payer: Cigna of CA HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

BORIC ACID (BULK) POWDER [1131]

Facility

$0.95

Service Code	NDC 3877900648
Hospital Charge Code	NDG1131A
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.57
Rate for Payer: Aetna of CA Government/Medicare	$0.57
Rate for Payer: Cash Price	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

Know your out-of-pocket cost for care.

All Charges