Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RUXOLITINIB 20 MG TABLET [153889]

Facility

$333.72

Service Code	NDC 50881-020-60
Hospital Charge Code	ERX153889
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$250.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.23
Rate for Payer: Aetna of CA Government/Medicare	$200.23
Rate for Payer: Cash Price	$150.17
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 25 MG TABLET [153890]

Facility

$333.72

Service Code	NDC 50881-025-60
Hospital Charge Code	ERX153890
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$266.98
Rate for Payer: Cash Price	$150.17
Rate for Payer: Cigna of CA HMO/PPO	$266.98
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 25 MG TABLET [153890]

Facility

$333.72

Service Code	NDC 50881-025-60
Hospital Charge Code	ERX153890
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$250.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.23
Rate for Payer: Aetna of CA Government/Medicare	$200.23
Rate for Payer: Cash Price	$150.17
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 5 MG TABLET [153886]

Facility

$333.72

Service Code	NDC 50881-005-60
Hospital Charge Code	ERX153886
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$250.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.23
Rate for Payer: Aetna of CA Government/Medicare	$200.23
Rate for Payer: Cash Price	$150.17
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 5 MG TABLET [153886]

Facility

$333.72

Service Code	NDC 50881-005-60
Hospital Charge Code	ERX153886
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$266.98
Rate for Payer: Cash Price	$150.17
Rate for Payer: Cigna of CA HMO/PPO	$266.98
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]

Facility

$2,814.28

Service Code	NDC 55135-132-01
Hospital Charge Code	ERX227764
Hospital Revenue Code	636
Min. Negotiated Rate	$1,547.85
Max. Negotiated Rate	$2,251.42
Rate for Payer: Cash Price	$1,266.43
Rate for Payer: Cigna of CA HMO/PPO	$2,251.42
Rate for Payer: Health Smart Auto/Commercial	$1,688.57
Rate for Payer: LLUH Dept of Risk Management WC	$1,547.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,110.71

SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [227764]

Facility

$2,814.28

Service Code	NDC 55135-132-01
Hospital Charge Code	ERX227764
Hospital Revenue Code	636
Min. Negotiated Rate	$1,547.85
Max. Negotiated Rate	$2,110.71
Rate for Payer: Health Smart Auto/Commercial	$1,688.57
Rate for Payer: Cash Price	$1,266.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,688.57
Rate for Payer: Aetna of CA Government/Medicare	$1,688.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,688.57
Rate for Payer: LLUH Dept of Risk Management WC	$1,547.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,110.71

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]

Facility

$13.36

Service Code	NDC 0078-0659-20
Hospital Charge Code	ERX210397
Hospital Revenue Code	259
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.69
Rate for Payer: Cash Price	$6.01
Rate for Payer: Cigna of CA HMO/PPO	$10.69
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.02

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [210397]

Facility

$13.36

Service Code	NDC 0078-0659-20
Hospital Charge Code	ERX210397
Hospital Revenue Code	259
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.02
Rate for Payer: Aetna of CA Government/Medicare	$8.02
Rate for Payer: Cash Price	$6.01
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.02

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$13.36

Service Code	NDC 0078-0777-20
Hospital Charge Code	ERX210398
Hospital Revenue Code	259
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.02
Rate for Payer: Aetna of CA Government/Medicare	$8.02
Rate for Payer: Cash Price	$6.01
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.02

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [210398]

Facility

$13.36

Service Code	NDC 0078-0777-20
Hospital Charge Code	ERX210398
Hospital Revenue Code	259
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.69
Rate for Payer: Cash Price	$6.01
Rate for Payer: Cigna of CA HMO/PPO	$10.69
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.02

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]

Facility

$13.36

Service Code	NDC 0078-0696-20
Hospital Charge Code	ERX210399
Hospital Revenue Code	259
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.69
Rate for Payer: Cash Price	$6.01
Rate for Payer: Cigna of CA HMO/PPO	$10.69
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.02

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [210399]

Facility

$13.36

Service Code	NDC 0078-0696-20
Hospital Charge Code	ERX210399
Hospital Revenue Code	259
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.02
Rate for Payer: Aetna of CA Government/Medicare	$8.02
Rate for Payer: Cash Price	$6.01
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.02

SALICYLIC ACID 17 % TOPICAL LIQUID [11323]

Facility

$0.62

Service Code	NDC 1101725220
Hospital Charge Code	NDG11323
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

SALICYLIC ACID 17 % TOPICAL LIQUID [11323]

Facility

$0.62

Service Code	NDC 1101725220
Hospital Charge Code	NDG11323
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]

Facility

$0.14

Service Code	NDC 4858251201
Hospital Charge Code	NDG216603
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL [216603]

Facility

$0.14

Service Code	NDC 4858251201
Hospital Charge Code	NDG216603
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.33

Service Code	NDC 73090-0800-02
Hospital Charge Code	NDG117779A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.36

Service Code	NDC 6014629157
Hospital Charge Code	NDG117779A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.27

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.36

Service Code	NDC 8489800001
Hospital Charge Code	1719220
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
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	$0.16
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 Beech St/Commercial/PHCS	$0.27

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.36

Service Code	NDC 8489800001
Hospital Charge Code	1719220
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.27

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.36

Service Code	NDC 6014629157
Hospital Charge Code	NDG117779A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
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	$0.16
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 Beech St/Commercial/PHCS	$0.27

SALIVA SUBSTITUTE COMBO NO.2 [117779]

Facility

$0.33

Service Code	NDC 73090-0800-02
Hospital Charge Code	NDG117779A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

SAQUINAVIR 500 MG TABLET [40401]

Facility

$12.02

Service Code	NDC 0004-0244-51
Hospital Charge Code	1710991
Hospital Revenue Code	259
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$9.62
Rate for Payer: Cash Price	$5.41
Rate for Payer: Cigna of CA HMO/PPO	$9.62
Rate for Payer: Health Smart Auto/Commercial	$7.21
Rate for Payer: LLUH Dept of Risk Management WC	$6.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.02

SAQUINAVIR 500 MG TABLET [40401]

Facility

$12.02

Service Code	NDC 0004-0244-51
Hospital Charge Code	1710991
Hospital Revenue Code	259
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$9.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.21
Rate for Payer: Aetna of CA Government/Medicare	$7.21
Rate for Payer: Cash Price	$5.41
Rate for Payer: Health Smart Auto/Commercial	$7.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.21
Rate for Payer: LLUH Dept of Risk Management WC	$6.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.02

Know your out-of-pocket cost for care.

All Charges