Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-33
Hospital Charge Code	1711870
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.72
Rate for Payer: Aetna of CA Government/Medicare	$9.72
Rate for Payer: Cash Price	$7.29
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-32
Hospital Charge Code	1711870
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Cash Price	$7.29
Rate for Payer: Cigna of CA HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$21.89

Service Code	NDC 51079-020-03
Hospital Charge Code	1711870
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$17.51
Rate for Payer: Cash Price	$9.85
Rate for Payer: Cigna of CA HMO/PPO	$17.51
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.42

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-32
Hospital Charge Code	1711870
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.72
Rate for Payer: Aetna of CA Government/Medicare	$9.72
Rate for Payer: Cash Price	$7.29
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$16.20

Service Code	NDC 60687-596-33
Hospital Charge Code	1711870
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Cash Price	$7.29
Rate for Payer: Cigna of CA HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.15

BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [31576]

Facility

$21.89

Service Code	NDC 51079-020-01
Hospital Charge Code	1711870
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$16.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.13
Rate for Payer: Aetna of CA Government/Medicare	$13.13
Rate for Payer: Cash Price	$9.85
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.42

BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81454]

Facility

$53.07

Service Code	NDC 0186-0370-28
Hospital Charge Code	1744122
Hospital Revenue Code	259
Min. Negotiated Rate	$29.19
Max. Negotiated Rate	$42.46
Rate for Payer: Cash Price	$23.88
Rate for Payer: Cigna of CA HMO/PPO	$42.46
Rate for Payer: Health Smart Auto/Commercial	$31.84
Rate for Payer: LLUH Dept of Risk Management WC	$29.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.80

BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81454]

Facility

$53.07

Service Code	NDC 0186-0370-28
Hospital Charge Code	1744122
Hospital Revenue Code	259
Min. Negotiated Rate	$29.19
Max. Negotiated Rate	$39.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.84
Rate for Payer: Aetna of CA Government/Medicare	$31.84
Rate for Payer: Cash Price	$23.88
Rate for Payer: Health Smart Auto/Commercial	$31.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.84
Rate for Payer: LLUH Dept of Risk Management WC	$29.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.80

BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]

Facility

$40.12

Service Code	NDC 0186-0372-28
Hospital Charge Code	1744123
Hospital Revenue Code	259
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$32.10
Rate for Payer: Cash Price	$18.05
Rate for Payer: Cigna of CA HMO/PPO	$32.10
Rate for Payer: Health Smart Auto/Commercial	$24.07
Rate for Payer: LLUH Dept of Risk Management WC	$22.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.09

BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]

Facility

$40.12

Service Code	NDC 0186-0372-28
Hospital Charge Code	1744123
Hospital Revenue Code	259
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$30.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.07
Rate for Payer: Aetna of CA Government/Medicare	$24.07
Rate for Payer: Cash Price	$18.05
Rate for Payer: Health Smart Auto/Commercial	$24.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.07
Rate for Payer: LLUH Dept of Risk Management WC	$22.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.09

BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]

Facility

$40.19

Service Code	NDC 0186-0372-20
Hospital Charge Code	NDG81453
Hospital Revenue Code	259
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$30.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.11
Rate for Payer: Aetna of CA Government/Medicare	$24.11
Rate for Payer: Cash Price	$18.09
Rate for Payer: Health Smart Auto/Commercial	$24.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.11
Rate for Payer: LLUH Dept of Risk Management WC	$22.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.14

BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [81453]

Facility

$40.19

Service Code	NDC 0186-0372-20
Hospital Charge Code	NDG81453
Hospital Revenue Code	259
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$32.15
Rate for Payer: Cash Price	$18.09
Rate for Payer: Cigna of CA HMO/PPO	$32.15
Rate for Payer: Health Smart Auto/Commercial	$24.11
Rate for Payer: LLUH Dept of Risk Management WC	$22.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.14

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]

Facility

$0.40

Service Code	CPT S0171
Hospital Charge Code	1720423
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.16
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	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]

Facility

$0.91

Service Code	CPT S0171
Hospital Charge Code	1720424
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.72
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]

Facility

$0.39

Service Code	CPT S0171
Hospital Charge Code	1720423
Hospital Revenue Code	636
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

BUMETANIDE 0.25 MG/ML INJECTION SOLUTION [9308]

Facility

$0.91

Service Code	CPT S0171
Hospital Charge Code	1720424
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
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: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$1.52

Service Code	NDC 50268-130-11
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.54

Service Code	NDC 0185-0128-05
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.69

Service Code	NDC 0832-0540-11
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.41

Service Code	NDC 42799-119-01
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.41

Service Code	NDC 69238-1489-1
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.41

Service Code	NDC 69238-1489-1
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$1.52

Service Code	NDC 50268-130-11
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.54

Service Code	NDC 0185-0128-05
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

BUMETANIDE 0.5 MG TABLET [9309]

Facility

$0.69

Service Code	NDC 0832-0540-11
Hospital Charge Code	1712005
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

Know your out-of-pocket cost for care.

All Charges