Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$2.72

Service Code	NDC 0409-1761-02
Hospital Charge Code	1720900
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.18
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.18
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.04

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$1.56

Service Code	NDC 0409-3613-11
Hospital Charge Code	1720900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]

Facility

$0.32

Service Code	CPT J0665
Hospital Charge Code	1712420
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]

Facility

$0.19

Service Code	CPT J0665
Hospital Charge Code	1721219
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]

Facility

$0.19

Service Code	CPT J0665
Hospital Charge Code	1721219
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [1224]

Facility

$0.27

Service Code	CPT J0665
Hospital Charge Code	1712420
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]

Facility

$95.32

Service Code	NDC 0093-3657-21
Hospital Charge Code	ERX107661
Hospital Revenue Code	259
Min. Negotiated Rate	$52.43
Max. Negotiated Rate	$76.26
Rate for Payer: Cash Price	$42.89
Rate for Payer: Cigna of CA HMO/PPO	$76.26
Rate for Payer: Health Smart Auto/Commercial	$57.19
Rate for Payer: LLUH Dept of Risk Management WC	$52.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.49

BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]

Facility

$95.32

Service Code	NDC 0093-3657-40
Hospital Charge Code	ERX107661
Hospital Revenue Code	259
Min. Negotiated Rate	$52.43
Max. Negotiated Rate	$76.26
Rate for Payer: Cash Price	$42.89
Rate for Payer: Cigna of CA HMO/PPO	$76.26
Rate for Payer: Health Smart Auto/Commercial	$57.19
Rate for Payer: LLUH Dept of Risk Management WC	$52.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.49

BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]

Facility

$95.32

Service Code	NDC 0093-3657-21
Hospital Charge Code	ERX107661
Hospital Revenue Code	259
Min. Negotiated Rate	$52.43
Max. Negotiated Rate	$71.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.19
Rate for Payer: Aetna of CA Government/Medicare	$57.19
Rate for Payer: Cash Price	$42.89
Rate for Payer: Health Smart Auto/Commercial	$57.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.19
Rate for Payer: LLUH Dept of Risk Management WC	$52.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.49

BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107661]

Facility

$95.32

Service Code	NDC 0093-3657-40
Hospital Charge Code	ERX107661
Hospital Revenue Code	259
Min. Negotiated Rate	$52.43
Max. Negotiated Rate	$71.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.19
Rate for Payer: Aetna of CA Government/Medicare	$57.19
Rate for Payer: Cash Price	$42.89
Rate for Payer: Health Smart Auto/Commercial	$57.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.19
Rate for Payer: LLUH Dept of Risk Management WC	$52.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.49

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

Facility

$4.24

Service Code	CPT J0572
Hospital Charge Code	ERX106176
Hospital Revenue Code	636
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.60
Rate for Payer: Aetna of CA Government/Medicare	$2.54
Rate for Payer: Aetna of CA Government/Medicare	$1.60
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Smart Auto/Commercial	$2.54
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.00

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

Facility

$4.24

Service Code	CPT J0572
Hospital Charge Code	ERX106176
Hospital Revenue Code	636
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$3.39
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cigna of CA HMO/PPO	$3.39
Rate for Payer: Cigna of CA HMO/PPO	$2.14
Rate for Payer: Health Smart Auto/Commercial	$2.54
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	$2.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.18

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

Facility

$1.33

Service Code	CPT J0572
Hospital Charge Code	1734058
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cigna of CA HMO/PPO	$1.06
Rate for Payer: Cigna of CA 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: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.83

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

Facility

$1.11

Service Code	CPT J0572
Hospital Charge Code	1734058
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.83
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	$0.80
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.67
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: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]

Facility

$64.43

Service Code	NDC 42858-750-40
Hospital Charge Code	ERX107660
Hospital Revenue Code	259
Min. Negotiated Rate	$35.44
Max. Negotiated Rate	$48.32
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	$28.99
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 Beech St/Commercial/PHCS	$48.32

BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]

Facility

$64.43

Service Code	NDC 42858-750-40
Hospital Charge Code	ERX107660
Hospital Revenue Code	259
Min. Negotiated Rate	$35.44
Max. Negotiated Rate	$51.54
Rate for Payer: Cash Price	$28.99
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$48.32

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

Facility

$4.09

Service Code	CPT J0574
Hospital Charge Code	ERX34714
Hospital Revenue Code	636
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$3.07
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	$2.45
Rate for Payer: Aetna of CA Government/Medicare	$2.87
Rate for Payer: Cash Price	$2.15
Rate for Payer: Cash Price	$1.84
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	$2.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: LLUH Dept of Risk Management WC	$2.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.58

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

Facility

$4.09

Service Code	CPT J0574
Hospital Charge Code	ERX34714
Hospital Revenue Code	636
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$3.27
Rate for Payer: Cash Price	$1.84
Rate for Payer: Cash Price	$2.15
Rate for Payer: Cigna of CA HMO/PPO	$3.27
Rate for Payer: Cigna of CA 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	$2.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.07

BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]

Facility

$16.34

Service Code	CPT J0592
Hospital Charge Code	NDG117588
Hospital Revenue Code	636
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$12.26
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	$7.35
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 Beech St/Commercial/PHCS	$12.26

BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]

Facility

$16.34

Service Code	CPT J0592
Hospital Charge Code	NDG117588
Hospital Revenue Code	636
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$13.07
Rate for Payer: Cash Price	$7.35
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$12.26

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]

Facility

$0.37

Service Code	CPT J0571
Hospital Charge Code	ERX34711
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
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	$0.17
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	$0.28

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]

Facility

$0.37

Service Code	CPT J0571
Hospital Charge Code	ERX34711
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
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	$0.28

BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]

Facility

$4.20

Service Code	CPT J0571
Hospital Charge Code	ERX34712
Hospital Revenue Code	636
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$1.89
Rate for Payer: Cash Price	$0.90
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	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]

Facility

$4.20

Service Code	CPT J0571
Hospital Charge Code	ERX34712
Hospital Revenue Code	636
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$1.89
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.60
Rate for Payer: Cigna of CA HMO/PPO	$3.36
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	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.15

BUPROPION HCL 100 MG TABLET [9321]

Facility

$0.44

Service Code	NDC 23155-192-01
Hospital Charge Code	1711391
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.33

Know your out-of-pocket cost for care.

All Charges