Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [14983]

Facility

$0.47

Service Code	NDC 63323-461-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
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	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [14983]

Facility

$0.47

Service Code	NDC 63323-461-57
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
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	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [14983]

Facility

$0.47

Service Code	NDC 63323-461-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
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	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14984]

Facility

$0.50

Service Code	NDC 63323-463-57
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14984]

Facility

$0.50

Service Code	NDC 63323-463-57
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14984]

Facility

$0.50

Service Code	NDC 63323-463-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14984]

Facility

$0.50

Service Code	NDC 63323-463-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]

Facility

$0.81

Service Code	NDC 0409-1746-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]

Facility

$0.81

Service Code	NDC 0409-1746-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]

Facility

$0.81

Service Code	NDC 0409-1746-70
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [105633]

Facility

$0.81

Service Code	NDC 0409-1746-70
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]

Facility

$0.82

Service Code	NDC 0409-1749-70
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]

Facility

$0.82

Service Code	NDC 0409-1749-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]

Facility

$0.82

Service Code	NDC 0409-1749-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]

Facility

$0.82

Service Code	NDC 0409-1749-70
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

BUPIVACAINE-EPINEPHRINE (PF) 0.75 %-1:200,000 INJECTION SOLUTION [114890]

Facility

$0.59

Service Code	NDC 63323-460-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

BUPIVACAINE-EPINEPHRINE (PF) 0.75 %-1:200,000 INJECTION SOLUTION [114890]

Facility

$0.59

Service Code	NDC 63323-460-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

BUPIVACAINE-EPINEPHRINE (PF) 0.75 %-1:200,000 INJECTION SOLUTION [114890]

Facility

$0.59

Service Code	NDC 63323-460-37
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

BUPIVACAINE-EPINEPHRINE (PF) 0.75 %-1:200,000 INJECTION SOLUTION [114890]

Facility

$0.59

Service Code	NDC 63323-460-37
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.30

Service Code	NDC 63323-465-57
Hospital Charge Code	901700004
Hospital Revenue Code	250
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	$0.17
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.30

Service Code	NDC 63323-465-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
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	$0.17
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.09

Service Code	NDC 55150-249-50
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.09

Service Code	NDC 0409-1160-18
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.09

Service Code	NDC 0409-1160-18
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.09

Service Code	NDC 0409-1160-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges