Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$12.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.86
Rate for Payer: Aetna of CA Government/Medicare	$9.86
Rate for Payer: Cash Price	$7.40
Rate for Payer: Health Smart Auto/Commercial	$9.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.86
Rate for Payer: LLUH Dept of Risk Management WC	$9.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.33

BOSUTINIB 100 MG TABLET [197246]

Facility

$194.83

Service Code	NDC 0069-0135-01
Hospital Charge Code	ERX197246
Hospital Revenue Code	259
Min. Negotiated Rate	$107.16
Max. Negotiated Rate	$155.86
Rate for Payer: Cash Price	$87.67
Rate for Payer: Cigna of CA HMO/PPO	$155.86
Rate for Payer: Health Smart Auto/Commercial	$116.90
Rate for Payer: LLUH Dept of Risk Management WC	$107.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$146.12

BOSUTINIB 100 MG TABLET [197246]

Facility

$194.83

Service Code	NDC 0069-0135-01
Hospital Charge Code	ERX197246
Hospital Revenue Code	259
Min. Negotiated Rate	$107.16
Max. Negotiated Rate	$146.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$116.90
Rate for Payer: Aetna of CA Government/Medicare	$116.90
Rate for Payer: Cash Price	$87.67
Rate for Payer: Health Smart Auto/Commercial	$116.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$116.90
Rate for Payer: LLUH Dept of Risk Management WC	$107.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$146.12

BOSUTINIB 400 MG TABLET [220449]

Facility

$779.30

Service Code	NDC 0069-0193-01
Hospital Charge Code	ERX220449
Hospital Revenue Code	259
Min. Negotiated Rate	$428.62
Max. Negotiated Rate	$584.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$467.58
Rate for Payer: Aetna of CA Government/Medicare	$467.58
Rate for Payer: Cash Price	$350.69
Rate for Payer: Health Smart Auto/Commercial	$467.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$467.58
Rate for Payer: LLUH Dept of Risk Management WC	$428.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$584.48

BOSUTINIB 400 MG TABLET [220449]

Facility

$779.30

Service Code	NDC 0069-0193-01
Hospital Charge Code	ERX220449
Hospital Revenue Code	259
Min. Negotiated Rate	$428.62
Max. Negotiated Rate	$623.44
Rate for Payer: Cash Price	$350.69
Rate for Payer: Cigna of CA HMO/PPO	$623.44
Rate for Payer: Health Smart Auto/Commercial	$467.58
Rate for Payer: LLUH Dept of Risk Management WC	$428.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$584.48

BOSUTINIB 500 MG TABLET [197247]

Facility

$779.30

Service Code	NDC 0069-0136-01
Hospital Charge Code	ERX197247
Hospital Revenue Code	259
Min. Negotiated Rate	$428.62
Max. Negotiated Rate	$584.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$467.58
Rate for Payer: Aetna of CA Government/Medicare	$467.58
Rate for Payer: Cash Price	$350.69
Rate for Payer: Health Smart Auto/Commercial	$467.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$467.58
Rate for Payer: LLUH Dept of Risk Management WC	$428.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$584.48

BOSUTINIB 500 MG TABLET [197247]

Facility

$779.30

Service Code	NDC 0069-0136-01
Hospital Charge Code	ERX197247
Hospital Revenue Code	259
Min. Negotiated Rate	$428.62
Max. Negotiated Rate	$623.44
Rate for Payer: Cash Price	$350.69
Rate for Payer: Cigna of CA HMO/PPO	$623.44
Rate for Payer: Health Smart Auto/Commercial	$467.58
Rate for Payer: LLUH Dept of Risk Management WC	$428.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$584.48

BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]

Facility

$271,800.00

Service Code	NDC 68403-1100-6
Hospital Charge Code	NDG213747
Hospital Revenue Code	636
Min. Negotiated Rate	$149,490.00
Max. Negotiated Rate	$203,850.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$163,080.00
Rate for Payer: Aetna of CA Government/Medicare	$163,080.00
Rate for Payer: Cash Price	$122,310.00
Rate for Payer: Health Smart Auto/Commercial	$163,080.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$163,080.00
Rate for Payer: LLUH Dept of Risk Management WC	$149,490.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$203,850.00

BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]

Facility

$271,800.00

Service Code	NDC 68403-1100-6
Hospital Charge Code	NDG213747
Hospital Revenue Code	636
Min. Negotiated Rate	$149,490.00
Max. Negotiated Rate	$217,440.00
Rate for Payer: Health Smart Auto/Commercial	$163,080.00
Rate for Payer: Cash Price	$122,310.00
Rate for Payer: Cigna of CA HMO/PPO	$217,440.00
Rate for Payer: LLUH Dept of Risk Management WC	$149,490.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$203,850.00

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]

Facility

$13,053.60

Service Code	NDC 51144-050-01
Hospital Charge Code	1755786
Hospital Revenue Code	636
Min. Negotiated Rate	$7,179.48
Max. Negotiated Rate	$9,790.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7,832.16
Rate for Payer: Aetna of CA Government/Medicare	$7,832.16
Rate for Payer: Cash Price	$5,874.12
Rate for Payer: Health Smart Auto/Commercial	$7,832.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7,832.16
Rate for Payer: LLUH Dept of Risk Management WC	$7,179.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,790.20

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]

Facility

$13,053.60

Service Code	NDC 51144-050-01
Hospital Charge Code	1755786
Hospital Revenue Code	636
Min. Negotiated Rate	$7,179.48
Max. Negotiated Rate	$10,442.88
Rate for Payer: Cash Price	$5,874.12
Rate for Payer: Cigna of CA HMO/PPO	$10,442.88
Rate for Payer: Health Smart Auto/Commercial	$7,832.16
Rate for Payer: LLUH Dept of Risk Management WC	$7,179.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,790.20

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$36.80

Service Code	NDC 61314-144-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$27.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.08
Rate for Payer: Aetna of CA Government/Medicare	$22.08
Rate for Payer: Cash Price	$16.56
Rate for Payer: Health Smart Auto/Commercial	$22.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.08
Rate for Payer: LLUH Dept of Risk Management WC	$20.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.60

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$49.75

Service Code	NDC 0023-9177-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$37.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.85
Rate for Payer: Aetna of CA Government/Medicare	$29.85
Rate for Payer: Cash Price	$22.39
Rate for Payer: Health Smart Auto/Commercial	$29.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.85
Rate for Payer: LLUH Dept of Risk Management WC	$27.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.31

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$49.75

Service Code	NDC 0023-9177-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$39.80
Rate for Payer: Cash Price	$22.39
Rate for Payer: Cigna of CA HMO/PPO	$39.80
Rate for Payer: Health Smart Auto/Commercial	$29.85
Rate for Payer: LLUH Dept of Risk Management WC	$27.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.31

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility

$36.80

Service Code	NDC 61314-144-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$29.44
Rate for Payer: Cash Price	$16.56
Rate for Payer: Cigna of CA HMO/PPO	$29.44
Rate for Payer: Health Smart Auto/Commercial	$22.08
Rate for Payer: LLUH Dept of Risk Management WC	$20.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.60

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$3.53

Service Code	NDC 17478-715-10
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$2.82
Rate for Payer: Cash Price	$1.59
Rate for Payer: Cigna of CA HMO/PPO	$2.82
Rate for Payer: Health Smart Auto/Commercial	$2.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.65

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$2.40

Service Code	NDC 61314-143-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$3.48

Service Code	NDC 24208-411-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.09
Rate for Payer: Aetna of CA Government/Medicare	$2.09
Rate for Payer: Cash Price	$1.57
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.61

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$3.53

Service Code	NDC 17478-715-10
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$2.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.12
Rate for Payer: Aetna of CA Government/Medicare	$2.12
Rate for Payer: Cash Price	$1.59
Rate for Payer: Health Smart Auto/Commercial	$2.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.65

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$2.40

Service Code	NDC 61314-143-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$0.80

Service Code	NDC 70069-232-01
Hospital Charge Code	NDG17881B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$3.48

Service Code	NDC 24208-411-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Cash Price	$1.57
Rate for Payer: Cigna of CA HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.61

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility

$0.80

Service Code	NDC 70069-232-01
Hospital Charge Code	NDG17881B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$42.55

Service Code	NDC 60505-0589-1
Hospital Charge Code	NDG87834A
Hospital Revenue Code	259
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$31.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.53
Rate for Payer: Aetna of CA Government/Medicare	$25.53
Rate for Payer: Cash Price	$19.15
Rate for Payer: Health Smart Auto/Commercial	$25.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.53
Rate for Payer: LLUH Dept of Risk Management WC	$23.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.91

BRIMONIDINE 0.2 %-TIMOLOL 0.5 % EYE DROPS [87834]

Facility

$48.99

Service Code	NDC 0023-9211-05
Hospital Charge Code	NDG87834A
Hospital Revenue Code	259
Min. Negotiated Rate	$26.94
Max. Negotiated Rate	$36.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.39
Rate for Payer: Aetna of CA Government/Medicare	$29.39
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Smart Auto/Commercial	$29.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.39
Rate for Payer: LLUH Dept of Risk Management WC	$26.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.74

Know your out-of-pocket cost for care.

All Charges