Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM [106176]

Facility

$2.67

Service Code	HCPCS J0572
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.14
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cash Price	$1.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.71
Rate for Payer: Health Smart Auto/Commercial	$2.03
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.86
Rate for Payer: Multiplan Commercial	$2.54
Rate for Payer: Multiplan Commercial	$2.00

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]

Facility

$3.04

Service Code	HCPCS J0572
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.89
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Commercial	$1.00
Rate for Payer: Multiplan Commercial	$2.28

BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]

Facility

$3.04

Service Code	HCPCS J0572
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$1.82
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Commercial	$1.00
Rate for Payer: Multiplan Commercial	$2.28

BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]

Facility

$64.43

Service Code	NDC 42858-750-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$35.44
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$35.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.54
Rate for Payer: Health Smart Auto/Commercial	$38.66
Rate for Payer: LLUH Dept of Risk Management WC	$35.44
Rate for Payer: Multiplan Commercial	$48.32

BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]

Facility

$64.43

Service Code	NDC 42858-750-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$35.44
Max. Negotiated Rate	$51.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.66
Rate for Payer: Aetna of CA Government/Medicare	$38.66
Rate for Payer: Cash Price	$35.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.54
Rate for Payer: Health Smart Auto/Commercial	$38.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.66
Rate for Payer: LLUH Dept of Risk Management WC	$35.44
Rate for Payer: Multiplan Commercial	$48.32

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]

Facility

$4.78

Service Code	HCPCS J0574
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$2.63
Rate for Payer: Cash Price	$2.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.82
Rate for Payer: Health Smart Auto/Commercial	$2.87
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: Multiplan Commercial	$3.06
Rate for Payer: Multiplan Commercial	$3.58

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]

Facility

$4.08

Service Code	HCPCS J0574
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.87
Rate for Payer: Aetna of CA Government/Medicare	$2.87
Rate for Payer: Aetna of CA Government/Medicare	$2.45
Rate for Payer: Cash Price	$2.63
Rate for Payer: Cash Price	$2.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.82
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: Health Smart Auto/Commercial	$2.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: Multiplan Commercial	$3.58
Rate for Payer: Multiplan Commercial	$3.06

BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]

Facility

$16.34

Service Code	HCPCS J0592
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$13.07
Rate for Payer: Cash Price	$8.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.07
Rate for Payer: Health Smart Auto/Commercial	$9.80
Rate for Payer: LLUH Dept of Risk Management WC	$8.99
Rate for Payer: Multiplan Commercial	$12.26

BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]

Facility

$16.34

Service Code	HCPCS J0592
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$13.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.80
Rate for Payer: Aetna of CA Government/Medicare	$9.80
Rate for Payer: Cash Price	$8.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.07
Rate for Payer: Health Smart Auto/Commercial	$9.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.80
Rate for Payer: LLUH Dept of Risk Management WC	$8.99
Rate for Payer: Multiplan Commercial	$12.26

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]

Facility

$0.64

Service Code	HCPCS J0571
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]

Facility

$0.64

Service Code	HCPCS J0571
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]

Facility

$4.20

Service Code	HCPCS J0571
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$0.72
Rate for Payer: Multiplan Commercial	$1.50
Rate for Payer: Multiplan Commercial	$3.15

BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]

Facility

$4.20

Service Code	HCPCS J0571
Hospital Charge Code	901700054
Hospital Revenue Code	636
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cash Price	$2.31
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$0.72
Rate for Payer: Multiplan Commercial	$1.50
Rate for Payer: Multiplan Commercial	$3.15

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.80

Service Code	NDC 68001-309-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

BUPROPION HCL 100 MG TABLET [9321]

Facility

$2.12

Service Code	NDC 50268-143-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.59

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.80

Service Code	NDC 68001-309-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

BUPROPION HCL 100 MG TABLET [9321]

Facility

$2.12

Service Code	NDC 50268-143-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.59

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.86

Service Code	NDC 60505-0157-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.44

Service Code	NDC 23155-192-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.44

Service Code	NDC 23155-192-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

BUPROPION HCL 100 MG TABLET [9321]

Facility

$2.12

Service Code	NDC 50268-143-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.59

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.05

Service Code	NDC 0904-7530-60
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

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.86

Service Code	NDC 60505-0157-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

BUPROPION HCL 100 MG TABLET [9321]

Facility

$2.12

Service Code	NDC 50268-143-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.59

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.05

Service Code	NDC 0904-7530-60
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

Know your out-of-pocket cost for care.

All Charges