Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$33.76

Service Code	NDC 70710-1014-3
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$18.57
Max. Negotiated Rate	$25.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.26
Rate for Payer: Aetna of CA Government/Medicare	$20.26
Rate for Payer: Cash Price	$15.19
Rate for Payer: Health Smart Auto/Commercial	$20.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.26
Rate for Payer: LLUH Dept of Risk Management WC	$18.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.32

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$48.00

Service Code	NDC 69238-1051-3
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.80
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.00

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$48.00

Service Code	NDC 69238-1051-3
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$38.40
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna of CA HMO/PPO	$38.40
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.00

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$80.85

Service Code	NDC 60687-381-94
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$44.47
Max. Negotiated Rate	$60.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.51
Rate for Payer: Aetna of CA Government/Medicare	$48.51
Rate for Payer: Cash Price	$36.38
Rate for Payer: Health Smart Auto/Commercial	$48.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.51
Rate for Payer: LLUH Dept of Risk Management WC	$44.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.64

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$33.76

Service Code	NDC 70710-1014-3
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$18.57
Max. Negotiated Rate	$27.01
Rate for Payer: Cash Price	$15.19
Rate for Payer: Cigna of CA HMO/PPO	$27.01
Rate for Payer: Health Smart Auto/Commercial	$20.26
Rate for Payer: LLUH Dept of Risk Management WC	$18.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.32

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$80.85

Service Code	NDC 60687-381-11
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$44.47
Max. Negotiated Rate	$60.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.51
Rate for Payer: Aetna of CA Government/Medicare	$48.51
Rate for Payer: Cash Price	$36.38
Rate for Payer: Health Smart Auto/Commercial	$48.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.51
Rate for Payer: LLUH Dept of Risk Management WC	$44.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.64

PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]

Facility

$4,738.00

Service Code	CPT A9595
Hospital Charge Code	ERX231930
Hospital Revenue Code	343
Min. Negotiated Rate	$2,605.90
Max. Negotiated Rate	$3,790.40
Rate for Payer: Cash Price	$2,132.10
Rate for Payer: Cigna of CA HMO/PPO	$3,790.40
Rate for Payer: Health Smart Auto/Commercial	$2,842.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,605.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,553.50

PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]

Facility

$4,738.00

Service Code	CPT A9595
Hospital Charge Code	ERX231930
Hospital Revenue Code	343
Min. Negotiated Rate	$2,605.90
Max. Negotiated Rate	$3,553.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,842.80
Rate for Payer: Aetna of CA Government/Medicare	$2,842.80
Rate for Payer: Cash Price	$2,132.10
Rate for Payer: Health Smart Auto/Commercial	$2,842.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,842.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,605.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,553.50

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$5.05

Service Code	NDC 69238-1745-8
Hospital Charge Code	1740073
Hospital Revenue Code	259
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$4.04
Rate for Payer: Cash Price	$2.27
Rate for Payer: Cigna of CA HMO/PPO	$4.04
Rate for Payer: Health Smart Auto/Commercial	$3.03
Rate for Payer: LLUH Dept of Risk Management WC	$2.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.79

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$5.94

Service Code	NDC 70069-181-01
Hospital Charge Code	1740073
Hospital Revenue Code	259
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$4.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.56
Rate for Payer: Aetna of CA Government/Medicare	$3.56
Rate for Payer: Cash Price	$2.67
Rate for Payer: Health Smart Auto/Commercial	$3.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.56
Rate for Payer: LLUH Dept of Risk Management WC	$3.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.46

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$6.31

Service Code	NDC 61314-203-15
Hospital Charge Code	1740073
Hospital Revenue Code	259
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$5.05
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cigna of CA HMO/PPO	$5.05
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: LLUH Dept of Risk Management WC	$3.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.73

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$5.05

Service Code	NDC 69238-1745-8
Hospital Charge Code	1740073
Hospital Revenue Code	259
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$3.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.03
Rate for Payer: Aetna of CA Government/Medicare	$3.03
Rate for Payer: Cash Price	$2.27
Rate for Payer: Health Smart Auto/Commercial	$3.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.03
Rate for Payer: LLUH Dept of Risk Management WC	$2.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.79

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$5.94

Service Code	NDC 70069-181-01
Hospital Charge Code	1740073
Hospital Revenue Code	259
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$4.75
Rate for Payer: Cash Price	$2.67
Rate for Payer: Cigna of CA HMO/PPO	$4.75
Rate for Payer: Health Smart Auto/Commercial	$3.56
Rate for Payer: LLUH Dept of Risk Management WC	$3.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.46

PILOCARPINE 1 % EYE DROPS [6279]

Facility

$6.31

Service Code	NDC 61314-203-15
Hospital Charge Code	1740073
Hospital Revenue Code	259
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$4.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.79
Rate for Payer: Aetna of CA Government/Medicare	$3.79
Rate for Payer: Cash Price	$2.84
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.79
Rate for Payer: LLUH Dept of Risk Management WC	$3.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.73

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$6.07

Service Code	NDC 70069-191-01
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$4.86
Rate for Payer: Cash Price	$2.73
Rate for Payer: Cigna of CA HMO/PPO	$4.86
Rate for Payer: Health Smart Auto/Commercial	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.55

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$6.26

Service Code	NDC 17478-224-12
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$4.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.76
Rate for Payer: Aetna of CA Government/Medicare	$3.76
Rate for Payer: Cash Price	$2.82
Rate for Payer: Health Smart Auto/Commercial	$3.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.76
Rate for Payer: LLUH Dept of Risk Management WC	$3.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.70

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$6.07

Service Code	NDC 70069-191-01
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.64
Rate for Payer: Aetna of CA Government/Medicare	$3.64
Rate for Payer: Cash Price	$2.73
Rate for Payer: Health Smart Auto/Commercial	$3.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.55

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$6.45

Service Code	NDC 61314-204-15
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$5.16
Rate for Payer: Cash Price	$2.90
Rate for Payer: Cigna of CA HMO/PPO	$5.16
Rate for Payer: Health Smart Auto/Commercial	$3.87
Rate for Payer: LLUH Dept of Risk Management WC	$3.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.84

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$7.61

Service Code	NDC 0998-0204-15
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$5.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.57
Rate for Payer: Aetna of CA Government/Medicare	$4.57
Rate for Payer: Cash Price	$3.42
Rate for Payer: Health Smart Auto/Commercial	$4.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.57
Rate for Payer: LLUH Dept of Risk Management WC	$4.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.71

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$6.45

Service Code	NDC 61314-204-15
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$4.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.87
Rate for Payer: Aetna of CA Government/Medicare	$3.87
Rate for Payer: Cash Price	$2.90
Rate for Payer: Health Smart Auto/Commercial	$3.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.87
Rate for Payer: LLUH Dept of Risk Management WC	$3.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.84

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$7.61

Service Code	NDC 0998-0204-15
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$6.09
Rate for Payer: Cash Price	$3.42
Rate for Payer: Cigna of CA HMO/PPO	$6.09
Rate for Payer: Health Smart Auto/Commercial	$4.57
Rate for Payer: LLUH Dept of Risk Management WC	$4.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.71

PILOCARPINE 2 % EYE DROPS [6280]

Facility

$6.26

Service Code	NDC 17478-224-12
Hospital Charge Code	1740090
Hospital Revenue Code	259
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$5.01
Rate for Payer: Cash Price	$2.82
Rate for Payer: Cigna of CA HMO/PPO	$5.01
Rate for Payer: Health Smart Auto/Commercial	$3.76
Rate for Payer: LLUH Dept of Risk Management WC	$3.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.70

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$6.36

Service Code	NDC 70069-201-01
Hospital Charge Code	1740061
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.09
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cigna of CA HMO/PPO	$5.09
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.77

PILOCARPINE 4 % EYE DROPS [6282]

Facility

$6.36

Service Code	NDC 70069-201-01
Hospital Charge Code	1740061
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.77
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Cash Price	$2.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.77

PILOCARPINE 5 MG TABLET [12803]

Facility

$2.73

Service Code	NDC 68084-928-95
Hospital Charge Code	1711692
Hospital Revenue Code	259
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.64
Rate for Payer: Aetna of CA Government/Medicare	$1.64
Rate for Payer: Cash Price	$1.23
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.05

Know your out-of-pocket cost for care.

All Charges