Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE [8639]

Facility

$0.04

Service Code	NDC 35046-001-06
Hospital Charge Code	1712644
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.02
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 Beech St/Commercial/PHCS	$0.03

VITAMIN A ORAL SOLUTION (IV FORM) 50,000 UNITS/ML [4080447]

Facility

$20.89

Service Code	NDC 9994-0804-47
Hospital Charge Code	1715203
Hospital Revenue Code	259
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$16.71
Rate for Payer: Cash Price	$9.40
Rate for Payer: Cigna of CA HMO/PPO	$16.71
Rate for Payer: Health Smart Auto/Commercial	$12.53
Rate for Payer: LLUH Dept of Risk Management WC	$11.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.67

VITAMIN A ORAL SOLUTION (IV FORM) 50,000 UNITS/ML [4080447]

Facility

$20.89

Service Code	NDC 9994-0804-47
Hospital Charge Code	1715203
Hospital Revenue Code	259
Min. Negotiated Rate	$11.49
Max. Negotiated Rate	$15.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.53
Rate for Payer: Aetna of CA Government/Medicare	$12.53
Rate for Payer: Cash Price	$9.40
Rate for Payer: Health Smart Auto/Commercial	$12.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.53
Rate for Payer: LLUH Dept of Risk Management WC	$11.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.67

VITAMIN A PALMITATE 250 MCG-VIT C 50 MG-VIT D3 10 MCG/ML ORAL DROPS [228286]

Facility

$0.20

Service Code	NDC 87040303
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

VITAMIN A PALMITATE 250 MCG-VIT C 50 MG-VIT D3 10 MCG/ML ORAL DROPS [228286]

Facility

$0.20

Service Code	NDC 87040303
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]

Facility

$0.03

Service Code	NDC 4098521464
Hospital Charge Code	1711121
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.02

VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [113607]

Facility

$0.03

Service Code	NDC 4098521464
Hospital Charge Code	1711121
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: 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 Beech St/Commercial/PHCS	$0.02

VITAMIN A PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION [11641]

Facility

$431.25

Service Code	NDC 70199-026-11
Hospital Charge Code	NDG11641
Hospital Revenue Code	250
Min. Negotiated Rate	$237.19
Max. Negotiated Rate	$323.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$258.75
Rate for Payer: Aetna of CA Government/Medicare	$258.75
Rate for Payer: Cash Price	$194.06
Rate for Payer: Health Smart Auto/Commercial	$258.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$258.75
Rate for Payer: LLUH Dept of Risk Management WC	$237.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$323.44

VITAMIN A PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION [11641]

Facility

$431.25

Service Code	NDC 70199-026-11
Hospital Charge Code	NDG11641
Hospital Revenue Code	250
Min. Negotiated Rate	$237.19
Max. Negotiated Rate	$345.00
Rate for Payer: Cash Price	$194.06
Rate for Payer: Cigna of CA HMO/PPO	$345.00
Rate for Payer: Health Smart Auto/Commercial	$258.75
Rate for Payer: LLUH Dept of Risk Management WC	$237.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$323.44

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.07

Service Code	NDC 536478701
Hospital Charge Code	ERX804
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.07

Service Code	NDC 536478701
Hospital Charge Code	ERX804
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.06

Service Code	NDC 7985420080
Hospital Charge Code	ERX804
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

VITAMIN B COMPLEX CAPSULE [804]

Facility

$0.06

Service Code	NDC 7985420080
Hospital Charge Code	ERX804
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.31

Service Code	NDC 5026885711
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.09

Service Code	NDC 7985420090
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.31

Service Code	NDC 5026885711
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.09

Service Code	NDC 7985420090
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.07

Service Code	NDC 7985420185
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.07

Service Code	NDC 7985420185
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.31

Service Code	NDC 5026885715
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

VITAMIN B COMPLEX-FOLIC ACID 0.4 MG TABLET [117049]

Facility

$0.31

Service Code	NDC 5026885715
Hospital Charge Code	ERX117049
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

VITAMIN B COMPLEX TABLET [799]

Facility

$0.02

Service Code	NDC 4329255540
Hospital Charge Code	1710859
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
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: 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 Beech St/Commercial/PHCS	$0.02

VITAMIN B COMPLEX TABLET [799]

Facility

$0.02

Service Code	NDC 904418160
Hospital Charge Code	1710859
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

VITAMIN B COMPLEX TABLET [799]

Facility

$0.02

Service Code	NDC 4329255540
Hospital Charge Code	1710859
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

VITAMIN B COMPLEX TABLET [799]

Facility

$0.02

Service Code	NDC 904418160
Hospital Charge Code	1710859
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
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: 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 Beech St/Commercial/PHCS	$0.02

Know your out-of-pocket cost for care.

All Charges