Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]

Facility

$12.00

Service Code	NDC 55150-234-10
Hospital Charge Code	1756008
Hospital Revenue Code	250
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION [6393]

Facility

$12.00

Service Code	NDC 55150-234-10
Hospital Charge Code	1756008
Hospital Revenue Code	250
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna of CA HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]

Facility

$1.73

Service Code	NDC 5192723020
Hospital Charge Code	NDG192296
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.30

POLYOXYL (100) STEARYL ETHER (BULK) 100 % WAX [192296]

Facility

$1.73

Service Code	NDC 5192723020
Hospital Charge Code	NDG192296
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.30

POLYVINYL ALCOHOL 1.4 % EYE DROPS [27994]

Facility

$0.47

Service Code	NDC 17478-060-12
Hospital Charge Code	1740338
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

POLYVINYL ALCOHOL 1.4 % EYE DROPS [27994]

Facility

$0.47

Service Code	NDC 17478-060-12
Hospital Charge Code	1740338
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]

Facility

$435.45

Service Code	CPT J3490
Hospital Charge Code	1720928
Hospital Revenue Code	636
Min. Negotiated Rate	$239.50
Max. Negotiated Rate	$348.36
Rate for Payer: Cash Price	$195.95
Rate for Payer: Cigna of CA HMO/PPO	$348.36
Rate for Payer: Health Smart Auto/Commercial	$261.27
Rate for Payer: LLUH Dept of Risk Management WC	$239.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$326.59

PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION [27047]

Facility

$435.45

Service Code	CPT J3490
Hospital Charge Code	1720928
Hospital Revenue Code	636
Min. Negotiated Rate	$239.50
Max. Negotiated Rate	$326.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$261.27
Rate for Payer: Aetna of CA Government/Medicare	$261.27
Rate for Payer: Cash Price	$195.95
Rate for Payer: Health Smart Auto/Commercial	$261.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$261.27
Rate for Payer: LLUH Dept of Risk Management WC	$239.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$326.59

PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]

Facility

$429.33

Service Code	NDC 10122-510-03
Hospital Charge Code	1720929
Hospital Revenue Code	250
Min. Negotiated Rate	$236.13
Max. Negotiated Rate	$343.46
Rate for Payer: Cash Price	$193.20
Rate for Payer: Cigna of CA HMO/PPO	$343.46
Rate for Payer: Health Smart Auto/Commercial	$257.60
Rate for Payer: LLUH Dept of Risk Management WC	$236.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$322.00

PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION [117872]

Facility

$429.33

Service Code	NDC 10122-510-03
Hospital Charge Code	1720929
Hospital Revenue Code	250
Min. Negotiated Rate	$236.13
Max. Negotiated Rate	$322.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$257.60
Rate for Payer: Aetna of CA Government/Medicare	$257.60
Rate for Payer: Cash Price	$193.20
Rate for Payer: Health Smart Auto/Commercial	$257.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$257.60
Rate for Payer: LLUH Dept of Risk Management WC	$236.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$322.00

PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]

Facility

$25,980.00

Service Code	CPT J9600
Hospital Charge Code	ERX14472
Hospital Revenue Code	636
Min. Negotiated Rate	$14,289.00
Max. Negotiated Rate	$19,485.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15,588.00
Rate for Payer: Aetna of CA Government/Medicare	$15,588.00
Rate for Payer: Cash Price	$11,691.00
Rate for Payer: Health Smart Auto/Commercial	$15,588.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15,588.00
Rate for Payer: LLUH Dept of Risk Management WC	$14,289.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19,485.00

PORFIMER 75 MG INTRAVENOUS SOLUTION [14472]

Facility

$25,980.00

Service Code	CPT J9600
Hospital Charge Code	ERX14472
Hospital Revenue Code	636
Min. Negotiated Rate	$14,289.00
Max. Negotiated Rate	$20,784.00
Rate for Payer: Cash Price	$11,691.00
Rate for Payer: Cigna of CA HMO/PPO	$20,784.00
Rate for Payer: Health Smart Auto/Commercial	$15,588.00
Rate for Payer: LLUH Dept of Risk Management WC	$14,289.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19,485.00

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$56.60

Service Code	NDC 60687-523-21
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$31.13
Max. Negotiated Rate	$45.28
Rate for Payer: Cash Price	$25.47
Rate for Payer: Cigna of CA HMO/PPO	$45.28
Rate for Payer: Health Smart Auto/Commercial	$33.96
Rate for Payer: LLUH Dept of Risk Management WC	$31.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.45

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$19.24

Service Code	NDC 0527-2133-35
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$14.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.54
Rate for Payer: Aetna of CA Government/Medicare	$11.54
Rate for Payer: Cash Price	$8.66
Rate for Payer: Health Smart Auto/Commercial	$11.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.54
Rate for Payer: LLUH Dept of Risk Management WC	$10.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.43

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$56.60

Service Code	NDC 60687-523-11
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$31.13
Max. Negotiated Rate	$42.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.96
Rate for Payer: Aetna of CA Government/Medicare	$33.96
Rate for Payer: Cash Price	$25.47
Rate for Payer: Health Smart Auto/Commercial	$33.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.96
Rate for Payer: LLUH Dept of Risk Management WC	$31.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.45

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$82.24

Service Code	NDC 0085-4324-02
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$45.23
Max. Negotiated Rate	$61.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.34
Rate for Payer: Aetna of CA Government/Medicare	$49.34
Rate for Payer: Cash Price	$37.01
Rate for Payer: Health Smart Auto/Commercial	$49.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.34
Rate for Payer: LLUH Dept of Risk Management WC	$45.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.68

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$82.24

Service Code	NDC 0085-4324-02
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$45.23
Max. Negotiated Rate	$65.79
Rate for Payer: Cash Price	$37.01
Rate for Payer: Cigna of CA HMO/PPO	$65.79
Rate for Payer: Health Smart Auto/Commercial	$49.34
Rate for Payer: LLUH Dept of Risk Management WC	$45.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.68

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$9.00

Service Code	NDC 70748-258-07
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$6.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$4.05
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.75

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$9.00

Service Code	NDC 70748-258-07
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$4.05
Rate for Payer: Cigna of CA HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.75

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$56.60

Service Code	NDC 60687-523-11
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$31.13
Max. Negotiated Rate	$45.28
Rate for Payer: Cash Price	$25.47
Rate for Payer: Cigna of CA HMO/PPO	$45.28
Rate for Payer: Health Smart Auto/Commercial	$33.96
Rate for Payer: LLUH Dept of Risk Management WC	$31.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.45

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$56.60

Service Code	NDC 60687-523-21
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$31.13
Max. Negotiated Rate	$42.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.96
Rate for Payer: Aetna of CA Government/Medicare	$33.96
Rate for Payer: Cash Price	$25.47
Rate for Payer: Health Smart Auto/Commercial	$33.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.96
Rate for Payer: LLUH Dept of Risk Management WC	$31.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.45

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE [204306]

Facility

$19.24

Service Code	NDC 0527-2133-35
Hospital Charge Code	ERX204306
Hospital Revenue Code	259
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$15.39
Rate for Payer: Cash Price	$8.66
Rate for Payer: Cigna of CA HMO/PPO	$15.39
Rate for Payer: Health Smart Auto/Commercial	$11.54
Rate for Payer: LLUH Dept of Risk Management WC	$10.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.43

POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]

Facility

$16.45

Service Code	NDC 0085-1328-01
Hospital Charge Code	1715196
Hospital Revenue Code	259
Min. Negotiated Rate	$9.05
Max. Negotiated Rate	$12.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.87
Rate for Payer: Aetna of CA Government/Medicare	$9.87
Rate for Payer: Cash Price	$7.40
Rate for Payer: Health Smart Auto/Commercial	$9.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.87
Rate for Payer: LLUH Dept of Risk Management WC	$9.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.34

POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION [77371]

Facility

$16.45

Service Code	NDC 0085-1328-01
Hospital Charge Code	1715196
Hospital Revenue Code	259
Min. Negotiated Rate	$9.05
Max. Negotiated Rate	$13.16
Rate for Payer: Cash Price	$7.40
Rate for Payer: Cigna of CA HMO/PPO	$13.16
Rate for Payer: Health Smart Auto/Commercial	$9.87
Rate for Payer: LLUH Dept of Risk Management WC	$9.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.34

POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]

Facility

$38.12

Service Code	NDC 0085-4331-01
Hospital Charge Code	NDG2211
Hospital Revenue Code	250
Min. Negotiated Rate	$20.97
Max. Negotiated Rate	$28.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.87
Rate for Payer: Aetna of CA Government/Medicare	$22.87
Rate for Payer: Cash Price	$17.15
Rate for Payer: Health Smart Auto/Commercial	$22.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.87
Rate for Payer: LLUH Dept of Risk Management WC	$20.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.59

Know your out-of-pocket cost for care.

All Charges