Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

VALACYCLOVIR 500 MG TABLET [13133]

Facility

$0.47

Service Code	NDC 0378-4275-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
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	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
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 Commercial	$0.35

VALACYCLOVIR 500 MG TABLET [13133]

Facility

$0.48

Service Code	NDC 0378-4275-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

VALACYCLOVIR 500 MG TABLET [13133]

Facility

$0.48

Service Code	NDC 0378-4275-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

VALACYCLOVIR 500 MG TABLET [13133]

Facility

$0.98

Service Code	NDC 31722-704-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

VALACYCLOVIR 500 MG TABLET [13133]

Facility

$0.98

Service Code	NDC 31722-704-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

VALACYCLOVIR 500 MG TABLET [13133]

Facility

$0.98

Service Code	NDC 63304-904-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

VALACYCLOVIR ORAL SUSPENSION COMPOUND 50 MG/ML [4080355]

Facility

$0.72

Service Code	NDC 9994-0803-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

VALACYCLOVIR ORAL SUSPENSION COMPOUND 50 MG/ML [4080355]

Facility

$0.72

Service Code	NDC 9994-0803-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$19.13

Service Code	NDC 68084-965-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.52
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.48
Rate for Payer: Aetna of CA Government/Medicare	$11.48
Rate for Payer: Cash Price	$10.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.30
Rate for Payer: Health Smart Auto/Commercial	$11.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.48
Rate for Payer: LLUH Dept of Risk Management WC	$10.52
Rate for Payer: Multiplan Commercial	$14.35

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$14.83

Service Code	NDC 68084-965-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.90
Rate for Payer: Aetna of CA Government/Medicare	$8.90
Rate for Payer: Cash Price	$8.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.86
Rate for Payer: Health Smart Auto/Commercial	$8.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.90
Rate for Payer: LLUH Dept of Risk Management WC	$8.16
Rate for Payer: Multiplan Commercial	$11.12

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$5.00

Service Code	NDC 31722-832-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$19.13

Service Code	NDC 68084-965-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.52
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$10.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.30
Rate for Payer: Health Smart Auto/Commercial	$11.48
Rate for Payer: LLUH Dept of Risk Management WC	$10.52
Rate for Payer: Multiplan Commercial	$14.35

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$14.83

Service Code	NDC 68084-965-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.86
Rate for Payer: Cash Price	$8.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.86
Rate for Payer: Health Smart Auto/Commercial	$8.90
Rate for Payer: LLUH Dept of Risk Management WC	$8.16
Rate for Payer: Multiplan Commercial	$11.12

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$28.11

Service Code	NDC 55111-762-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$15.46
Max. Negotiated Rate	$22.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.87
Rate for Payer: Aetna of CA Government/Medicare	$16.87
Rate for Payer: Cash Price	$15.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.49
Rate for Payer: Health Smart Auto/Commercial	$16.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.87
Rate for Payer: LLUH Dept of Risk Management WC	$15.46
Rate for Payer: Multiplan Commercial	$21.08

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$19.13

Service Code	NDC 68084-965-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.52
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$10.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.30
Rate for Payer: Health Smart Auto/Commercial	$11.48
Rate for Payer: LLUH Dept of Risk Management WC	$10.52
Rate for Payer: Multiplan Commercial	$14.35

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$5.00

Service Code	NDC 31722-832-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$4.76

Service Code	NDC 65862-753-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$3.81
Rate for Payer: Cash Price	$2.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.81
Rate for Payer: Health Smart Auto/Commercial	$2.86
Rate for Payer: LLUH Dept of Risk Management WC	$2.62
Rate for Payer: Multiplan Commercial	$3.57

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$14.83

Service Code	NDC 68084-965-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.90
Rate for Payer: Aetna of CA Government/Medicare	$8.90
Rate for Payer: Cash Price	$8.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.86
Rate for Payer: Health Smart Auto/Commercial	$8.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.90
Rate for Payer: LLUH Dept of Risk Management WC	$8.16
Rate for Payer: Multiplan Commercial	$11.12

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$106.08

Service Code	NDC 0004-0038-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$58.34
Max. Negotiated Rate	$84.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$63.65
Rate for Payer: Aetna of CA Government/Medicare	$63.65
Rate for Payer: Cash Price	$58.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.86
Rate for Payer: Health Smart Auto/Commercial	$63.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$63.65
Rate for Payer: LLUH Dept of Risk Management WC	$58.34
Rate for Payer: Multiplan Commercial	$79.56

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$5.00

Service Code	NDC 27241-158-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$19.13

Service Code	NDC 68084-965-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.52
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.48
Rate for Payer: Aetna of CA Government/Medicare	$11.48
Rate for Payer: Cash Price	$10.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.30
Rate for Payer: Health Smart Auto/Commercial	$11.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.48
Rate for Payer: LLUH Dept of Risk Management WC	$10.52
Rate for Payer: Multiplan Commercial	$14.35

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$14.83

Service Code	NDC 68084-965-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.86
Rate for Payer: Cash Price	$8.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.86
Rate for Payer: Health Smart Auto/Commercial	$8.90
Rate for Payer: LLUH Dept of Risk Management WC	$8.16
Rate for Payer: Multiplan Commercial	$11.12

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$5.00

Service Code	NDC 27241-158-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$106.08

Service Code	NDC 0004-0038-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$58.34
Max. Negotiated Rate	$84.86
Rate for Payer: Cash Price	$58.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.86
Rate for Payer: Health Smart Auto/Commercial	$63.65
Rate for Payer: LLUH Dept of Risk Management WC	$58.34
Rate for Payer: Multiplan Commercial	$79.56

VALGANCICLOVIR 450 MG TABLET [30148]

Facility

$4.76

Service Code	NDC 65862-753-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$3.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.86
Rate for Payer: Aetna of CA Government/Medicare	$2.86
Rate for Payer: Cash Price	$2.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.81
Rate for Payer: Health Smart Auto/Commercial	$2.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.86
Rate for Payer: LLUH Dept of Risk Management WC	$2.62
Rate for Payer: Multiplan Commercial	$3.57

Know your out-of-pocket cost for care.

All Charges