Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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

$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

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

Facility

$1.10

Service Code	NDC 69097-318-86
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 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$5.60

Service Code	NDC 60687-524-79
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.36
Rate for Payer: Aetna of CA Government/Medicare	$3.36
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$5.60

Service Code	NDC 60687-524-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$0.60

Service Code	NDC 68180-984-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$0.60

Service Code	NDC 68180-984-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$5.60

Service Code	NDC 60687-524-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.36
Rate for Payer: Aetna of CA Government/Medicare	$3.36
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$0.60

Service Code	NDC 68180-984-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$5.60

Service Code	NDC 60687-524-79
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$0.60

Service Code	NDC 68180-984-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$5.58

Service Code	NDC 0487-9701-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$4.46
Rate for Payer: Cash Price	$3.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.46
Rate for Payer: Health Smart Auto/Commercial	$3.35
Rate for Payer: LLUH Dept of Risk Management WC	$3.07
Rate for Payer: Multiplan Commercial	$4.18

BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [28775]

Facility

$5.58

Service Code	NDC 0487-9701-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$4.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.35
Rate for Payer: Aetna of CA Government/Medicare	$3.35
Rate for Payer: Cash Price	$3.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.46
Rate for Payer: Health Smart Auto/Commercial	$3.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.35
Rate for Payer: LLUH Dept of Risk Management WC	$3.07
Rate for Payer: Multiplan Commercial	$4.18

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$2.67

Service Code	NDC 68382-720-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.60
Rate for Payer: Aetna of CA Government/Medicare	$1.60
Rate for Payer: Cash Price	$1.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.14
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.47
Rate for Payer: Multiplan Commercial	$2.00

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$21.89

Service Code	NDC 51079-020-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$17.51
Rate for Payer: Cash Price	$12.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.51
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Commercial	$16.42

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$1.19

Service Code	NDC 0574-9855-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$21.89

Service Code	NDC 51079-020-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$17.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.13
Rate for Payer: Aetna of CA Government/Medicare	$13.13
Rate for Payer: Cash Price	$12.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.51
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Commercial	$16.42

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$21.89

Service Code	NDC 51079-020-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$17.51
Rate for Payer: Cash Price	$12.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.51
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Commercial	$16.42

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$1.19

Service Code	NDC 0574-9855-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Cash Price	$8.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Commercial	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.72
Rate for Payer: Aetna of CA Government/Medicare	$9.72
Rate for Payer: Cash Price	$8.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Commercial	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$21.89

Service Code	NDC 51079-020-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$17.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.13
Rate for Payer: Aetna of CA Government/Medicare	$13.13
Rate for Payer: Cash Price	$12.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.51
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Commercial	$16.42

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Cash Price	$8.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Commercial	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.72
Rate for Payer: Aetna of CA Government/Medicare	$9.72
Rate for Payer: Cash Price	$8.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Commercial	$12.15

Know your out-of-pocket cost for care.

All Charges