Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$1,923.60

Service Code	NDC 63020-049-01
Hospital Charge Code	ERX35839
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.98
Max. Negotiated Rate	$1,442.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,154.16
Rate for Payer: Aetna of CA Government/Medicare	$1,154.16
Rate for Payer: Cash Price	$865.62
Rate for Payer: Health Smart Auto/Commercial	$1,154.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,154.16
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.70

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$240.00

Service Code	NDC 70860-225-10
Hospital Charge Code	ERX35839
Hospital Revenue Code	636
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$192.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna of CA HMO/PPO	$192.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$180.00

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$300.00

Service Code	NDC 43598-426-60
Hospital Charge Code	ERX35839
Hospital Revenue Code	636
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$180.00
Rate for Payer: Aetna of CA Government/Medicare	$180.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Smart Auto/Commercial	$180.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$180.00
Rate for Payer: LLUH Dept of Risk Management WC	$165.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$225.00

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$300.00

Service Code	NDC 43598-426-60
Hospital Charge Code	ERX35839
Hospital Revenue Code	636
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$240.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna of CA HMO/PPO	$240.00
Rate for Payer: Health Smart Auto/Commercial	$180.00
Rate for Payer: LLUH Dept of Risk Management WC	$165.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$225.00

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$1,923.60

Service Code	NDC 63020-049-01
Hospital Charge Code	ERX35839
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.98
Max. Negotiated Rate	$1,538.88
Rate for Payer: Cash Price	$865.62
Rate for Payer: Cigna of CA HMO/PPO	$1,538.88
Rate for Payer: Health Smart Auto/Commercial	$1,154.16
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.70

BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [35839]

Facility

$240.00

Service Code	NDC 70860-225-10
Hospital Charge Code	ERX35839
Hospital Revenue Code	636
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$144.00
Rate for Payer: Aetna of CA Government/Medicare	$144.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$144.00
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$180.00

BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION [220799]

Facility

$1,923.58

Service Code	CPT J9048
Hospital Charge Code	ERX220799
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.97
Max. Negotiated Rate	$1,538.86
Rate for Payer: Cash Price	$865.61
Rate for Payer: Cigna of CA HMO/PPO	$1,538.86
Rate for Payer: Health Smart Auto/Commercial	$1,154.15
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.68

BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION [220799]

Facility

$1,923.58

Service Code	CPT J9048
Hospital Charge Code	ERX220799
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.97
Max. Negotiated Rate	$1,442.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,154.15
Rate for Payer: Aetna of CA Government/Medicare	$1,154.15
Rate for Payer: Cash Price	$865.61
Rate for Payer: Health Smart Auto/Commercial	$1,154.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,154.15
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.68

BORTEZOMIB 3.5 MG IV INJECTION. [408035839]

Facility

$1,923.58

Service Code	CPT J9041
Hospital Charge Code	1755707
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.97
Max. Negotiated Rate	$1,442.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,154.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,154.16
Rate for Payer: Aetna of CA Government/Medicare	$1,154.15
Rate for Payer: Aetna of CA Government/Medicare	$1,154.16
Rate for Payer: Cash Price	$865.61
Rate for Payer: Cash Price	$865.62
Rate for Payer: Health Smart Auto/Commercial	$1,154.15
Rate for Payer: Health Smart Auto/Commercial	$1,154.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,154.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,154.15
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.98
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.70

BORTEZOMIB 3.5 MG IV INJECTION. [408035839]

Facility

$1,923.58

Service Code	CPT J9041
Hospital Charge Code	1755707
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.97
Max. Negotiated Rate	$1,538.86
Rate for Payer: Cash Price	$865.61
Rate for Payer: Cash Price	$865.62
Rate for Payer: Cigna of CA HMO/PPO	$1,538.88
Rate for Payer: Cigna of CA HMO/PPO	$1,538.86
Rate for Payer: Health Smart Auto/Commercial	$1,154.15
Rate for Payer: Health Smart Auto/Commercial	$1,154.16
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.97
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.68

BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]

Facility

$1,923.60

Service Code	CPT J9041
Hospital Charge Code	ERX40835839
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.98
Max. Negotiated Rate	$1,442.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,154.16
Rate for Payer: Aetna of CA Government/Medicare	$1,154.16
Rate for Payer: Cash Price	$865.62
Rate for Payer: Health Smart Auto/Commercial	$1,154.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,154.16
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.70

BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION SQ [40835839]

Facility

$1,923.60

Service Code	CPT J9041
Hospital Charge Code	ERX40835839
Hospital Revenue Code	636
Min. Negotiated Rate	$1,057.98
Max. Negotiated Rate	$1,538.88
Rate for Payer: Cash Price	$865.62
Rate for Payer: Cigna of CA HMO/PPO	$1,538.88
Rate for Payer: Health Smart Auto/Commercial	$1,154.16
Rate for Payer: LLUH Dept of Risk Management WC	$1,057.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,442.70

BOSENTAN 125 MG TABLET [31876]

Facility

$23.26

Service Code	NDC 68382-447-14
Hospital Charge Code	1710988
Hospital Revenue Code	259
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$17.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.96
Rate for Payer: Aetna of CA Government/Medicare	$13.96
Rate for Payer: Cash Price	$10.47
Rate for Payer: Health Smart Auto/Commercial	$13.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.96
Rate for Payer: LLUH Dept of Risk Management WC	$12.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.44

BOSENTAN 125 MG TABLET [31876]

Facility

$23.26

Service Code	NDC 68382-447-14
Hospital Charge Code	1710988
Hospital Revenue Code	259
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$18.61
Rate for Payer: Cash Price	$10.47
Rate for Payer: Cigna of CA HMO/PPO	$18.61
Rate for Payer: Health Smart Auto/Commercial	$13.96
Rate for Payer: LLUH Dept of Risk Management WC	$12.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.44

BOSENTAN 62.5 MG TABLET [31875]

Facility

$23.26

Service Code	NDC 68382-446-14
Hospital Charge Code	1710987
Hospital Revenue Code	259
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$18.61
Rate for Payer: Cash Price	$10.47
Rate for Payer: Cigna of CA HMO/PPO	$18.61
Rate for Payer: Health Smart Auto/Commercial	$13.96
Rate for Payer: LLUH Dept of Risk Management WC	$12.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.44

BOSENTAN 62.5 MG TABLET [31875]

Facility

$23.26

Service Code	NDC 68382-446-14
Hospital Charge Code	1710987
Hospital Revenue Code	259
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$17.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.96
Rate for Payer: Aetna of CA Government/Medicare	$13.96
Rate for Payer: Cash Price	$10.47
Rate for Payer: Health Smart Auto/Commercial	$13.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.96
Rate for Payer: LLUH Dept of Risk Management WC	$12.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.44

BOSENTAN 62.5 MG TABLET [31875]

Facility

$232.63

Service Code	NDC 66215-101-06
Hospital Charge Code	1710987
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$174.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.58
Rate for Payer: Aetna of CA Government/Medicare	$139.58
Rate for Payer: Cash Price	$104.68
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN 62.5 MG TABLET [31875]

Facility

$232.63

Service Code	NDC 66215-101-03
Hospital Charge Code	1710987
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$186.10
Rate for Payer: Cash Price	$104.68
Rate for Payer: Cigna of CA HMO/PPO	$186.10
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN 62.5 MG TABLET [31875]

Facility

$232.63

Service Code	NDC 66215-101-03
Hospital Charge Code	1710987
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$174.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.58
Rate for Payer: Aetna of CA Government/Medicare	$139.58
Rate for Payer: Cash Price	$104.68
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN 62.5 MG TABLET [31875]

Facility

$232.63

Service Code	NDC 66215-101-06
Hospital Charge Code	1710987
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$186.10
Rate for Payer: Cash Price	$104.68
Rate for Payer: Cigna of CA HMO/PPO	$186.10
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN CRUSHED TABLET IN WATER [40831875]

Facility

$232.63

Service Code	NDC 66215-101-03
Hospital Charge Code	ERX40831875
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$186.10
Rate for Payer: Cash Price	$104.68
Rate for Payer: Cigna of CA HMO/PPO	$186.10
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN CRUSHED TABLET IN WATER [40831875]

Facility

$232.63

Service Code	NDC 66215-101-06
Hospital Charge Code	ERX40831875
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$174.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.58
Rate for Payer: Aetna of CA Government/Medicare	$139.58
Rate for Payer: Cash Price	$104.68
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN CRUSHED TABLET IN WATER [40831875]

Facility

$232.63

Service Code	NDC 66215-101-06
Hospital Charge Code	ERX40831875
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$186.10
Rate for Payer: Cash Price	$104.68
Rate for Payer: Cigna of CA HMO/PPO	$186.10
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN CRUSHED TABLET IN WATER [40831875]

Facility

$232.63

Service Code	NDC 66215-101-03
Hospital Charge Code	ERX40831875
Hospital Revenue Code	259
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$174.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.58
Rate for Payer: Aetna of CA Government/Medicare	$139.58
Rate for Payer: Cash Price	$104.68
Rate for Payer: Health Smart Auto/Commercial	$139.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.58
Rate for Payer: LLUH Dept of Risk Management WC	$127.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.47

BOSENTAN ORAL SUSPENSION COMPOUND 6.25MG/ML [40831876]

Facility

$16.44

Service Code	NDC 9940-8318-76
Hospital Charge Code	NDC40831876
Hospital Revenue Code	259
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$13.15
Rate for Payer: Cash Price	$7.40
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$12.33

Know your out-of-pocket cost for care.

All Charges