Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

WARFARIN 7.5 MG TABLET [8752]

Facility

$0.30

Service Code	NDC 6516276810
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

WARFARIN 7.5 MG TABLET [8752]

Facility

$0.70

Service Code	NDC 0832121801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

WARFARIN 7.5 MG TABLET [8752]

Facility

$0.70

Service Code	NDC 0832121801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

WARFARIN 7.5 MG TABLET [8752]

Facility

$0.70

Service Code	NDC 0832121889
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

WARFARIN 7.5 MG TABLET [8752]

Facility

$0.70

Service Code	NDC 0832121889
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

WARFARIN 7.5 MG TABLET [8752]

Facility

$0.30

Service Code	NDC 6516276810
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION [864]

Facility

$0.60

Service Code	HCPCS J3490
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION [864]

Facility

$0.60

Service Code	HCPCS J3490
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

WATER FOR INJECTION, STERILE 100 % INJECTION SOLUTION [11671]

Facility

$0.39

Service Code	HCPCS A4216
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.45
Rate for Payer: Multiplan Commercial	$0.28
Rate for Payer: Multiplan Commercial	$0.38
Rate for Payer: Multiplan Commercial	$0.15
Rate for Payer: Multiplan Commercial	$0.27
Rate for Payer: Multiplan Commercial	$0.29
Rate for Payer: Multiplan Commercial	$0.16

WATER FOR INJECTION, STERILE 100 % INJECTION SOLUTION [11671]

Facility

$0.20

Service Code	HCPCS A4216
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27
Rate for Payer: Multiplan Commercial	$0.45
Rate for Payer: Multiplan Commercial	$0.38
Rate for Payer: Multiplan Commercial	$0.29
Rate for Payer: Multiplan Commercial	$0.16
Rate for Payer: Multiplan Commercial	$0.15
Rate for Payer: Multiplan Commercial	$0.28

WATER FOR INJECTION, STERILE 100 % INTRAVENOUS SOLUTION [28400]

Facility

$0.02

Service Code	HCPCS J3490
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Multiplan Commercial	$0.01

WATER FOR INJECTION, STERILE 100 % INTRAVENOUS SOLUTION [28400]

Facility

$0.02

Service Code	HCPCS J3490
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Multiplan Commercial	$0.01

WATER FOR IRRIGATION, STERILE SOLUTION [7485]

Facility

$0.01

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

WATER FOR IRRIGATION, STERILE SOLUTION [7485]

Facility

$0.01

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214063608
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.12

Service Code	NDC 7214045231
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.12

Service Code	NDC 7214045231
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214063386
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214063386
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

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214003147
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

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214003147
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214063608
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

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]

Facility

$3.35

Service Code	NDC 0023031204
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.01
Rate for Payer: Aetna of CA Government/Medicare	$2.01
Rate for Payer: Cash Price	$1.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.68
Rate for Payer: Health Smart Auto/Commercial	$2.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.01
Rate for Payer: LLUH Dept of Risk Management WC	$1.84
Rate for Payer: Multiplan Commercial	$2.51

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]

Facility

$3.35

Service Code	NDC 0023031204
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.68
Rate for Payer: Cash Price	$1.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.68
Rate for Payer: Health Smart Auto/Commercial	$2.01
Rate for Payer: LLUH Dept of Risk Management WC	$1.84
Rate for Payer: Multiplan Commercial	$2.51

WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]

Facility

$2.34

Service Code	NDC 9999902239
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.75

Know your out-of-pocket cost for care.

All Charges