Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

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

Facility

$0.05

Service Code	NDC 8770140725
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

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

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

Facility

$0.05

Service Code	NDC 8770140725
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

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

Facility

$0.05

Service Code	NDC 0904208560
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

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: 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

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

$0.03

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: 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: 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

$0.05

Service Code	NDC 0904208560
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

VITAMIN A ORAL SOLUTION (IV FORM) 50,000 UNITS/ML [4080447]

Facility

$20.89

Service Code	NDC 9994-0804-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$16.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.53
Rate for Payer: Aetna of CA Government/Medicare	$12.53
Rate for Payer: Cash Price	$11.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.71
Rate for Payer: Health Smart Auto/Commercial	$12.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.53
Rate for Payer: LLUH Dept of Risk Management WC	$11.49
Rate for Payer: Multiplan Commercial	$15.67

VITAMIN A ORAL SOLUTION (IV FORM) 50,000 UNITS/ML [4080447]

Facility

$20.89

Service Code	NDC 9994-0804-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$16.71
Rate for Payer: Cash Price	$11.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.71
Rate for Payer: Health Smart Auto/Commercial	$12.53
Rate for Payer: LLUH Dept of Risk Management WC	$11.49
Rate for Payer: Multiplan Commercial	$15.67

VITAMIN A PALMITATE 20,000 IU (6,000 MCG) PER 1 ML ORAL DROPS [4082303]

Facility

$0.36

Service Code	NDC 1007847420
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

VITAMIN A PALMITATE 20,000 IU (6,000 MCG) PER 1 ML ORAL DROPS [4082303]

Facility

$0.36

Service Code	NDC 1007847420
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

VITAMIN A PALMITATE 250 MCG-VIT C 50 MG-VIT D3 10 MCG/ML ORAL DROPS [228286]

Facility

$0.20

Service Code	NDC 0087040303
Hospital Charge Code	901700003
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

VITAMIN A PALMITATE 250 MCG-VIT C 50 MG-VIT D3 10 MCG/ML ORAL DROPS [228286]

Facility

$0.20

Service Code	NDC 0087040303
Hospital Charge Code	901700003
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]

Facility

$0.03

Service Code	NDC 4098521464
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]

Facility

$0.03

Service Code	NDC 4098521464
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 PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION [11641]

Facility

$431.25

Service Code	NDC 70199-026-11
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$237.19
Max. Negotiated Rate	$345.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$258.75
Rate for Payer: Aetna of CA Government/Medicare	$258.75
Rate for Payer: Cash Price	$237.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$345.00
Rate for Payer: Health Smart Auto/Commercial	$258.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$258.75
Rate for Payer: LLUH Dept of Risk Management WC	$237.19
Rate for Payer: Multiplan Commercial	$323.44

VITAMIN A PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION [11641]

Facility

$431.25

Service Code	NDC 70199-026-11
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$237.19
Max. Negotiated Rate	$345.00
Rate for Payer: Cash Price	$237.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$345.00
Rate for Payer: Health Smart Auto/Commercial	$258.75
Rate for Payer: LLUH Dept of Risk Management WC	$237.19
Rate for Payer: Multiplan Commercial	$323.44

VITAMIN B COMPLEX AND C NO.10-FOLIC ACID 900 MCG/5 ML ORAL LIQUID [32716]

Facility

$0.09

Service Code	NDC 5485951608
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

VITAMIN B COMPLEX AND C NO.10-FOLIC ACID 900 MCG/5 ML ORAL LIQUID [32716]

Facility

$0.09

Service Code	NDC 5485951608
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.07

Service Code	NDC 0536478701
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.07

Service Code	NDC 0536137801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.07

Service Code	NDC 0536137801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.07

Service Code	NDC 0536478701
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

Know your out-of-pocket cost for care.

All Charges