Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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: LLUH Dept of Risk Management WC	$15.46
Rate for Payer: Multiplan Commercial	$21.08

VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]

Facility

$10.91

Service Code	NDC 0591-2579-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$8.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.55
Rate for Payer: Aetna of CA Government/Medicare	$6.55
Rate for Payer: Cash Price	$6.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.73
Rate for Payer: Health Smart Auto/Commercial	$6.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.55
Rate for Payer: LLUH Dept of Risk Management WC	$6.00
Rate for Payer: Multiplan Commercial	$8.18

VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]

Facility

$10.91

Service Code	NDC 70010-051-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.73
Rate for Payer: Health Smart Auto/Commercial	$6.55
Rate for Payer: LLUH Dept of Risk Management WC	$6.00
Rate for Payer: Multiplan Commercial	$8.18

VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]

Facility

$10.91

Service Code	NDC 70010-051-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$8.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.55
Rate for Payer: Aetna of CA Government/Medicare	$6.55
Rate for Payer: Cash Price	$6.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.73
Rate for Payer: Health Smart Auto/Commercial	$6.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.55
Rate for Payer: LLUH Dept of Risk Management WC	$6.00
Rate for Payer: Multiplan Commercial	$8.18

VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]

Facility

$10.91

Service Code	NDC 0591-2579-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.73
Rate for Payer: Health Smart Auto/Commercial	$6.55
Rate for Payer: LLUH Dept of Risk Management WC	$6.00
Rate for Payer: Multiplan Commercial	$8.18

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.61

Service Code	NDC 63323-494-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.56

Service Code	NDC 25021-797-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.56

Service Code	NDC 25021-797-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.61

Service Code	NDC 63323-494-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$0.49

Service Code	NDC 63323-494-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.68

Service Code	NDC 0143-9785-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.68

Service Code	NDC 0143-9785-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.68

Service Code	NDC 0143-9785-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.61

Service Code	NDC 63323-494-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$0.49

Service Code	NDC 63323-494-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
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	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
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	$0.27
Rate for Payer: Multiplan Commercial	$0.37

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.61

Service Code	NDC 63323-494-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$1.68

Service Code	NDC 0143-9785-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$0.49

Service Code	NDC 63323-494-16
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
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	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
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	$0.27
Rate for Payer: Multiplan Commercial	$0.37

VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]

Facility

$0.49

Service Code	NDC 63323-494-16
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

VALPROIC ACID 250 MG CAPSULE [8429]

Facility

$0.52

Service Code	NDC 0832-0310-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

VALPROIC ACID 250 MG CAPSULE [8429]

Facility

$0.51

Service Code	NDC 63739-086-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

VALPROIC ACID 250 MG CAPSULE [8429]

Facility

$0.51

Service Code	NDC 63739-086-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

VALPROIC ACID 250 MG CAPSULE [8429]

Facility

$0.52

Service Code	NDC 0832-0310-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

VALPROIC ACID 250 MG CAPSULE [8429]

Facility

$0.48

Service Code	NDC 0591-4012-01
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

VALPROIC ACID 250 MG CAPSULE [8429]

Facility

$0.48

Service Code	NDC 0591-4012-01
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

Know your out-of-pocket cost for care.

All Charges