Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE [11640]

Facility

$0.39

Service Code	NDC 68462-293-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]

Facility

$0.28

Service Code	NDC 75834-159-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]

Facility

$0.28

Service Code	NDC 75834-159-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]

Facility

$0.37

Service Code	NDC 68462-260-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]

Facility

$0.37

Service Code	NDC 68462-260-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

VERAPAMIL ORAL SUSPENSION COMPOUND 50 MG/ML [4080356]

Facility

$0.36

Service Code	NDC 9994-0803-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

VERAPAMIL ORAL SUSPENSION COMPOUND 50 MG/ML [4080356]

Facility

$0.36

Service Code	NDC 9994-0803-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

VILAZODONE 20 MG TABLET [109403]

Facility

$1.35

Service Code	NDC 72205-261-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.08
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.08
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.01

VILAZODONE 20 MG TABLET [109403]

Facility

$6.30

Service Code	NDC 62332-233-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

VILAZODONE 20 MG TABLET [109403]

Facility

$6.13

Service Code	NDC 60505-4773-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$4.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.68
Rate for Payer: Aetna of CA Government/Medicare	$3.68
Rate for Payer: Cash Price	$3.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.90
Rate for Payer: Health Smart Auto/Commercial	$3.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.68
Rate for Payer: LLUH Dept of Risk Management WC	$3.37
Rate for Payer: Multiplan Commercial	$4.60

VILAZODONE 20 MG TABLET [109403]

Facility

$1.35

Service Code	NDC 72205-261-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.81
Rate for Payer: Aetna of CA Government/Medicare	$0.81
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.08
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.01

VILAZODONE 20 MG TABLET [109403]

Facility

$6.30

Service Code	NDC 62332-233-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

VILAZODONE 20 MG TABLET [109403]

Facility

$6.13

Service Code	NDC 60505-4773-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$4.90
Rate for Payer: Cash Price	$3.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.90
Rate for Payer: Health Smart Auto/Commercial	$3.68
Rate for Payer: LLUH Dept of Risk Management WC	$3.37
Rate for Payer: Multiplan Commercial	$4.60

VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]

Facility

$6.45

Service Code	HCPCS J9360
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$5.16
Rate for Payer: Cash Price	$3.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.16
Rate for Payer: Health Smart Auto/Commercial	$3.87
Rate for Payer: LLUH Dept of Risk Management WC	$3.55
Rate for Payer: Multiplan Commercial	$4.84

VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]

Facility

$6.45

Service Code	HCPCS J9360
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$5.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.87
Rate for Payer: Aetna of CA Government/Medicare	$3.87
Rate for Payer: Cash Price	$3.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.16
Rate for Payer: Health Smart Auto/Commercial	$3.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.87
Rate for Payer: LLUH Dept of Risk Management WC	$3.55
Rate for Payer: Multiplan Commercial	$4.84

VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]

Facility

$21.30

Service Code	HCPCS J9370
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.71
Max. Negotiated Rate	$17.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.78
Rate for Payer: Aetna of CA Government/Medicare	$12.78
Rate for Payer: Cash Price	$11.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.04
Rate for Payer: Health Smart Auto/Commercial	$12.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.78
Rate for Payer: LLUH Dept of Risk Management WC	$11.71
Rate for Payer: Multiplan Commercial	$15.97

VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]

Facility

$21.30

Service Code	HCPCS J9370
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.71
Max. Negotiated Rate	$17.04
Rate for Payer: Cash Price	$11.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.04
Rate for Payer: Health Smart Auto/Commercial	$12.78
Rate for Payer: LLUH Dept of Risk Management WC	$11.71
Rate for Payer: Multiplan Commercial	$15.97

VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [120009]

Facility

$9.24

Service Code	HCPCS J9370
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$7.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.54
Rate for Payer: Aetna of CA Government/Medicare	$5.54
Rate for Payer: Cash Price	$5.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.39
Rate for Payer: Health Smart Auto/Commercial	$5.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.54
Rate for Payer: LLUH Dept of Risk Management WC	$5.08
Rate for Payer: Multiplan Commercial	$6.93

VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [120009]

Facility

$9.24

Service Code	HCPCS J9370
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$7.39
Rate for Payer: Cash Price	$5.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.39
Rate for Payer: Health Smart Auto/Commercial	$5.54
Rate for Payer: LLUH Dept of Risk Management WC	$5.08
Rate for Payer: Multiplan Commercial	$6.93

VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION [14203]

Facility

$30.00

Service Code	HCPCS J9390
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$16.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION [14203]

Facility

$30.00

Service Code	HCPCS J9390
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$16.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]

Facility

$21.60

Service Code	HCPCS J9390
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$17.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.96
Rate for Payer: Aetna of CA Government/Medicare	$12.96
Rate for Payer: Cash Price	$11.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.28
Rate for Payer: Health Smart Auto/Commercial	$12.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.96
Rate for Payer: LLUH Dept of Risk Management WC	$11.88
Rate for Payer: Multiplan Commercial	$16.20

VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]

Facility

$21.60

Service Code	HCPCS J9390
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$17.28
Rate for Payer: Cash Price	$11.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.28
Rate for Payer: Health Smart Auto/Commercial	$12.96
Rate for Payer: LLUH Dept of Risk Management WC	$11.88
Rate for Payer: Multiplan Commercial	$16.20

VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]

Facility

$0.03

Service Code	NDC 0761043310
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.02
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	$0.02

VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]

Facility

$0.04

Service Code	NDC 35046-001-06
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

Know your out-of-pocket cost for care.

All Charges