Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ACETIC ACID 2 % EAR SOLUTION [17801]

Facility

$2.24

Service Code	NDC 5281781615
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

ACETIC ACID 2 % EAR SOLUTION [17801]

Facility

$2.24

Service Code	NDC 5281781615
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

ACETIC ACID (BULK) 3 % LIQUID [15091]

Facility

$0.14

Service Code	NDC 5155200516
Hospital Charge Code	901700004
Hospital Revenue Code	250
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

ACETIC ACID (BULK) 3 % LIQUID [15091]

Facility

$0.14

Service Code	NDC 5155200516
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

ACETYLCHOLINE CHLORIDE (10 MG/ML) BASE FOR IC MIXTURE [4088832559]

Facility

$156.68

Service Code	NDC 2420853920
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Cash Price	$70.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCHOLINE CHLORIDE (10 MG/ML) BASE FOR IC MIXTURE [4088832559]

Facility

$156.68

Service Code	NDC 2420853920
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.01
Rate for Payer: Aetna of CA Government/Medicare	$94.01
Rate for Payer: Cash Price	$70.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]

Facility

$156.68

Service Code	NDC 2420853920
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Cash Price	$70.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]

Facility

$156.68

Service Code	NDC 2420853920
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.01
Rate for Payer: Aetna of CA Government/Medicare	$94.01
Rate for Payer: Cash Price	$70.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$3.40

Service Code	NDC 0517750425
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.04
Rate for Payer: Aetna of CA Government/Medicare	$2.04
Rate for Payer: Cash Price	$1.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.72
Rate for Payer: Health Smart Auto/Commercial	$2.04
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.04
Rate for Payer: LLUH Dept of Risk Management WC	$1.87
Rate for Payer: Multiplan Commercial	$2.55

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$3.83

Service Code	NDC 6332369522
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.87

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$3.40

Service Code	NDC 0517750425
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.72
Rate for Payer: Cash Price	$1.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.72
Rate for Payer: Health Smart Auto/Commercial	$2.04
Rate for Payer: LLUH Dept of Risk Management WC	$1.87
Rate for Payer: Multiplan Commercial	$2.55

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$3.40

Service Code	NDC 0517750401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.04
Rate for Payer: Aetna of CA Government/Medicare	$2.04
Rate for Payer: Cash Price	$1.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.72
Rate for Payer: Health Smart Auto/Commercial	$2.04
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.04
Rate for Payer: LLUH Dept of Risk Management WC	$1.87
Rate for Payer: Multiplan Commercial	$2.55

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$4.37

Service Code	NDC 6332369504
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.50
Rate for Payer: Cash Price	$1.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.50
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$3.28

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$0.96

Service Code	NDC 0409330703
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.43
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: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$4.37

Service Code	NDC 6332369504
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.62
Rate for Payer: Aetna of CA Government/Medicare	$2.62
Rate for Payer: Cash Price	$1.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.50
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$3.28

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$0.96

Service Code	NDC 0409330703
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.43
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: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$3.83

Service Code	NDC 6332369522
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.87

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

$3.40

Service Code	NDC 0517750401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.72
Rate for Payer: Cash Price	$1.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.72
Rate for Payer: Health Smart Auto/Commercial	$2.04
Rate for Payer: LLUH Dept of Risk Management WC	$1.87
Rate for Payer: Multiplan Commercial	$2.55

ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]

Facility

$1.48

Service Code	HCPCS J0132
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$0.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$3.30
Rate for Payer: Multiplan Commercial	$1.60
Rate for Payer: Multiplan Commercial	$1.12
Rate for Payer: Multiplan Commercial	$1.11

ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]

Facility

$1.50

Service Code	HCPCS J0132
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$0.89
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.89
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Commercial	$1.60
Rate for Payer: Multiplan Commercial	$1.11
Rate for Payer: Multiplan Commercial	$1.12
Rate for Payer: Multiplan Commercial	$3.30

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$1.19

Service Code	NDC 6332369030
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$0.26

Service Code	NDC 6332369041
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$4.79

Service Code	NDC 6332369404
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.83
Rate for Payer: Health Smart Auto/Commercial	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: Multiplan Commercial	$3.59

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$4.52

Service Code	NDC 0517760425
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$3.62
Rate for Payer: Cash Price	$2.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.62
Rate for Payer: Health Smart Auto/Commercial	$2.71
Rate for Payer: LLUH Dept of Risk Management WC	$2.49
Rate for Payer: Multiplan Commercial	$3.39

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$4.52

Service Code	NDC 0517760401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.71
Rate for Payer: Aetna of CA Government/Medicare	$2.71
Rate for Payer: Cash Price	$2.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.62
Rate for Payer: Health Smart Auto/Commercial	$2.71
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.71
Rate for Payer: LLUH Dept of Risk Management WC	$2.49
Rate for Payer: Multiplan Commercial	$3.39

Know your out-of-pocket cost for care.

All Charges