Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]

Facility

$369.36

Service Code	HCPCS 90691
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$203.15
Max. Negotiated Rate	$295.49
Rate for Payer: Cash Price	$203.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$295.49
Rate for Payer: Health Smart Auto/Commercial	$221.62
Rate for Payer: LLUH Dept of Risk Management WC	$203.15
Rate for Payer: Multiplan Commercial	$277.02

TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]

Facility

$369.36

Service Code	HCPCS 90691
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$203.15
Max. Negotiated Rate	$295.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$221.62
Rate for Payer: Aetna of CA Government/Medicare	$221.62
Rate for Payer: Cash Price	$203.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$295.49
Rate for Payer: Health Smart Auto/Commercial	$221.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$221.62
Rate for Payer: LLUH Dept of Risk Management WC	$203.15
Rate for Payer: Multiplan Commercial	$277.02

UREA 10 % LOTION [19779]

Facility

$0.04

Service Code	NDC 5898060880
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.03

UREA 10 % LOTION [19779]

Facility

$0.04

Service Code	NDC 5898060880
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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 Commercial	$0.03

UREA 15 GRAM ORAL POWDER PACKET [218764]

Facility

$4.35

Service Code	NDC 6253000011
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$3.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.61
Rate for Payer: Aetna of CA Government/Medicare	$2.61
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.48
Rate for Payer: Health Smart Auto/Commercial	$2.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.61
Rate for Payer: LLUH Dept of Risk Management WC	$2.39
Rate for Payer: Multiplan Commercial	$3.26

UREA 15 GRAM ORAL POWDER PACKET [218764]

Facility

$4.35

Service Code	NDC 6253000011
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.48
Rate for Payer: Health Smart Auto/Commercial	$2.61
Rate for Payer: LLUH Dept of Risk Management WC	$2.39
Rate for Payer: Multiplan Commercial	$3.26

UREA 20 % TOPICAL CREAM [19776]

Facility

$0.17

Service Code	NDC 0884044904
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

UREA 20 % TOPICAL CREAM [19776]

Facility

$0.17

Service Code	NDC 0884044904
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

UREA 20 % TOPICAL CREAM [19776]

Facility

$0.10

Service Code	NDC 0536110945
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

UREA 20 % TOPICAL CREAM [19776]

Facility

$0.10

Service Code	NDC 0536110945
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

UREA(C14) 37 KBQ (1 MICROCI) CAPSULE [233734]

Facility

$42.08

Service Code	HCPCS A4641
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$33.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.25
Rate for Payer: Aetna of CA Government/Medicare	$25.25
Rate for Payer: Cash Price	$23.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.66
Rate for Payer: Health Smart Auto/Commercial	$25.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.25
Rate for Payer: LLUH Dept of Risk Management WC	$23.14
Rate for Payer: Multiplan Commercial	$31.56

UREA(C14) 37 KBQ (1 MICROCI) CAPSULE [233734]

Facility

$42.08

Service Code	HCPCS A4641
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$33.66
Rate for Payer: Cash Price	$23.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.66
Rate for Payer: Health Smart Auto/Commercial	$25.25
Rate for Payer: LLUH Dept of Risk Management WC	$23.14
Rate for Payer: Multiplan Commercial	$31.56

URSODIOL 250 MG TABLET [22660]

Facility

$4.20

Service Code	NDC 60687-527-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

URSODIOL 250 MG TABLET [22660]

Facility

$4.20

Service Code	NDC 60687-527-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

URSODIOL 250 MG TABLET [22660]

Facility

$3.95

Service Code	NDC 0904-6890-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.37
Rate for Payer: Aetna of CA Government/Medicare	$2.37
Rate for Payer: Cash Price	$2.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.16
Rate for Payer: Health Smart Auto/Commercial	$2.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.37
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

URSODIOL 250 MG TABLET [22660]

Facility

$4.20

Service Code	NDC 60687-527-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

URSODIOL 250 MG TABLET [22660]

Facility

$4.20

Service Code	NDC 60687-527-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

URSODIOL 250 MG TABLET [22660]

Facility

$3.95

Service Code	NDC 0904-6890-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.16
Rate for Payer: Cash Price	$2.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.16
Rate for Payer: Health Smart Auto/Commercial	$2.37
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

URSODIOL 300 MG CAPSULE [11624]

Facility

$7.14

Service Code	NDC 60687-100-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.28
Rate for Payer: Aetna of CA Government/Medicare	$4.28
Rate for Payer: Cash Price	$3.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.71
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Commercial	$5.36

URSODIOL 300 MG CAPSULE [11624]

Facility

$1.23

Service Code	NDC 0591-3159-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Commercial	$0.92

URSODIOL 300 MG CAPSULE [11624]

Facility

$7.14

Service Code	NDC 60687-100-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.28
Rate for Payer: Aetna of CA Government/Medicare	$4.28
Rate for Payer: Cash Price	$3.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.71
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Commercial	$5.36

URSODIOL 300 MG CAPSULE [11624]

Facility

$1.50

Service Code	NDC 42806-503-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

URSODIOL 300 MG CAPSULE [11624]

Facility

$7.14

Service Code	NDC 60687-100-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$5.71
Rate for Payer: Cash Price	$3.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.71
Rate for Payer: Health Smart Auto/Commercial	$4.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.93
Rate for Payer: Multiplan Commercial	$5.36

URSODIOL 300 MG CAPSULE [11624]

Facility

$1.23

Service Code	NDC 0591-3159-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Commercial	$0.92

URSODIOL 300 MG CAPSULE [11624]

Facility

$0.95

Service Code	NDC 59651-421-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
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	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.76
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 Commercial	$0.71

Know your out-of-pocket cost for care.

All Charges