Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CAFFEINE 200 MG TABLET [1259]

Facility

$0.16

Service Code	NDC 4601701840
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]

Facility

$7.20

Service Code	HCPCS J0706
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cash Price	$2.20
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.69
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Health Smart Auto/Commercial	$2.40
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00
Rate for Payer: Multiplan Commercial	$1.58
Rate for Payer: Multiplan Commercial	$5.40

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]

Facility

$2.11

Service Code	HCPCS J0706
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.69
Rate for Payer: Cash Price	$1.16
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cash Price	$2.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00
Rate for Payer: Multiplan Commercial	$1.58
Rate for Payer: Multiplan Commercial	$5.40

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]

Facility

$4.00

Service Code	NDC 9994-0804-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$2.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]

Facility

$4.00

Service Code	NDC 9994-0804-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$2.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]

Facility

$8.00

Service Code	NDC 25021-602-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Cash Price	$4.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Commercial	$6.00

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]

Facility

$17.67

Service Code	NDC 63323-406-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$14.14
Rate for Payer: Cash Price	$9.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.14
Rate for Payer: Health Smart Auto/Commercial	$10.60
Rate for Payer: LLUH Dept of Risk Management WC	$9.72
Rate for Payer: Multiplan Commercial	$13.25

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]

Facility

$8.00

Service Code	NDC 25021-602-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.80
Rate for Payer: Aetna of CA Government/Medicare	$4.80
Rate for Payer: Cash Price	$4.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Commercial	$6.00

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]

Facility

$17.67

Service Code	NDC 63323-406-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$14.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.60
Rate for Payer: Aetna of CA Government/Medicare	$10.60
Rate for Payer: Cash Price	$9.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.14
Rate for Payer: Health Smart Auto/Commercial	$10.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.60
Rate for Payer: LLUH Dept of Risk Management WC	$9.72
Rate for Payer: Multiplan Commercial	$13.25

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]

Facility

$23.48

Service Code	NDC 0517-2502-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$18.78
Rate for Payer: Cash Price	$12.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.78
Rate for Payer: Health Smart Auto/Commercial	$14.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.91
Rate for Payer: Multiplan Commercial	$17.61

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]

Facility

$23.48

Service Code	NDC 0517-2502-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$18.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.09
Rate for Payer: Aetna of CA Government/Medicare	$14.09
Rate for Payer: Cash Price	$12.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.78
Rate for Payer: Health Smart Auto/Commercial	$14.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.91
Rate for Payer: Multiplan Commercial	$17.61

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]

Facility

$23.48

Service Code	NDC 0517-2502-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$18.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.09
Rate for Payer: Aetna of CA Government/Medicare	$14.09
Rate for Payer: Cash Price	$12.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.78
Rate for Payer: Health Smart Auto/Commercial	$14.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.91
Rate for Payer: Multiplan Commercial	$17.61

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]

Facility

$23.48

Service Code	NDC 0517-2502-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$18.78
Rate for Payer: Cash Price	$12.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.78
Rate for Payer: Health Smart Auto/Commercial	$14.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.91
Rate for Payer: Multiplan Commercial	$17.61

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$0.03

Service Code	NDC 0395-0413-96
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$0.01

Service Code	NDC 0904-2533-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$0.03

Service Code	NDC 0395-0413-96
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]

Facility

$0.01

Service Code	NDC 0904-2533-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]

Facility

$4.41

Service Code	NDC 68462-501-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.65
Rate for Payer: Aetna of CA Government/Medicare	$2.65
Rate for Payer: Cash Price	$2.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.53
Rate for Payer: Health Smart Auto/Commercial	$2.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.65
Rate for Payer: LLUH Dept of Risk Management WC	$2.43
Rate for Payer: Multiplan Commercial	$3.31

CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]

Facility

$4.41

Service Code	NDC 68462-501-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.53
Rate for Payer: Health Smart Auto/Commercial	$2.65
Rate for Payer: LLUH Dept of Risk Management WC	$2.43
Rate for Payer: Multiplan Commercial	$3.31

CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]

Facility

$6.03

Service Code	NDC 66993-878-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.52

CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]

Facility

$6.03

Service Code	NDC 66993-878-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.62
Rate for Payer: Aetna of CA Government/Medicare	$3.62
Rate for Payer: Cash Price	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.52

CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]

Facility

$26.04

Service Code	NDC 50222-501-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$20.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.62
Rate for Payer: Aetna of CA Government/Medicare	$15.62
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.83
Rate for Payer: Health Smart Auto/Commercial	$15.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.62
Rate for Payer: LLUH Dept of Risk Management WC	$14.32
Rate for Payer: Multiplan Commercial	$19.53

CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]

Facility

$26.04

Service Code	NDC 50222-501-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$20.83
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.83
Rate for Payer: Health Smart Auto/Commercial	$15.62
Rate for Payer: LLUH Dept of Risk Management WC	$14.32
Rate for Payer: Multiplan Commercial	$19.53

CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]

Facility

$24.28

Service Code	NDC 60505-0823-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$19.42
Rate for Payer: Cash Price	$13.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.42
Rate for Payer: Health Smart Auto/Commercial	$14.57
Rate for Payer: LLUH Dept of Risk Management WC	$13.35
Rate for Payer: Multiplan Commercial	$18.21

CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]

Facility

$24.28

Service Code	NDC 60505-0823-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$19.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.57
Rate for Payer: Aetna of CA Government/Medicare	$14.57
Rate for Payer: Cash Price	$13.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.42
Rate for Payer: Health Smart Auto/Commercial	$14.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.57
Rate for Payer: LLUH Dept of Risk Management WC	$13.35
Rate for Payer: Multiplan Commercial	$18.21

Know your out-of-pocket cost for care.

All Charges