Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

VORINOSTAT ORAL SUSPENSION COMPOUND 50 MG/ML [4080357]

Facility

$49.35

Service Code	NDC 9994-0803-57
Hospital Charge Code	1715205
Hospital Revenue Code	259
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$22.21
Rate for Payer: Cigna of CA HMO/PPO	$39.48
Rate for Payer: Health Smart Auto/Commercial	$29.61
Rate for Payer: LLUH Dept of Risk Management WC	$27.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.01

VORINOSTAT ORAL SUSPENSION COMPOUND 50 MG/ML [4080357]

Facility

$49.35

Service Code	NDC 9994-0803-57
Hospital Charge Code	1715205
Hospital Revenue Code	259
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$37.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.61
Rate for Payer: Aetna of CA Government/Medicare	$29.61
Rate for Payer: Cash Price	$22.21
Rate for Payer: Health Smart Auto/Commercial	$29.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.61
Rate for Payer: LLUH Dept of Risk Management WC	$27.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.01

VOXELOTOR 500 MG TABLET [226660]

Facility

$152.38

Service Code	NDC 72786-101-01
Hospital Charge Code	ERX226660
Hospital Revenue Code	636
Min. Negotiated Rate	$83.81
Max. Negotiated Rate	$114.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$91.43
Rate for Payer: Aetna of CA Government/Medicare	$91.43
Rate for Payer: Cash Price	$68.57
Rate for Payer: Health Smart Auto/Commercial	$91.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$91.43
Rate for Payer: LLUH Dept of Risk Management WC	$83.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.28

VOXELOTOR 500 MG TABLET [226660]

Facility

$152.38

Service Code	NDC 72786-101-01
Hospital Charge Code	ERX226660
Hospital Revenue Code	636
Min. Negotiated Rate	$83.81
Max. Negotiated Rate	$121.90
Rate for Payer: Cash Price	$68.57
Rate for Payer: Cigna of CA HMO/PPO	$121.90
Rate for Payer: Health Smart Auto/Commercial	$91.43
Rate for Payer: LLUH Dept of Risk Management WC	$83.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.28

WARFARIN 0.5 MG PARTIAL TABLET [4081492]

Facility

$0.26

Service Code	NDC 9994-0814-92
Hospital Charge Code	NDC4081492
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

WARFARIN 0.5 MG PARTIAL TABLET [4081492]

Facility

$0.26

Service Code	NDC 9994-0814-92
Hospital Charge Code	NDC4081492
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

WARFARIN 10 MG TABLET [8748]

Facility

$0.44

Service Code	NDC 0093-1720-01
Hospital Charge Code	1710799
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

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-89
Hospital Charge Code	1710799
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

WARFARIN 10 MG TABLET [8748]

Facility

$0.44

Service Code	NDC 0093-1720-01
Hospital Charge Code	1710799
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.33
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	$0.20
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 Beech St/Commercial/PHCS	$0.33

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-01
Hospital Charge Code	1710799
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-89
Hospital Charge Code	1710799
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-01
Hospital Charge Code	1710799
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

WARFARIN 1.25 MG PARTIAL TABLET [4081918]

Facility

$1.33

Service Code	NDC 9994-0819-18
Hospital Charge Code	ERX4081918
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of CA HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

WARFARIN 1.25 MG PARTIAL TABLET [4081918]

Facility

$1.33

Service Code	NDC 9994-0819-18
Hospital Charge Code	ERX4081918
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

WARFARIN 1 MG TABLET [11664]

Facility

$0.44

Service Code	NDC 0832-1211-89
Hospital Charge Code	1711483
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

WARFARIN 1 MG TABLET [11664]

Facility

$0.44

Service Code	NDC 0832-1211-89
Hospital Charge Code	1711483
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.33
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	$0.20
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 Beech St/Commercial/PHCS	$0.33

WARFARIN 1 MG TABLET [11664]

Facility

$0.45

Service Code	NDC 0832-1211-01
Hospital Charge Code	1711483
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

WARFARIN 1 MG TABLET [11664]

Facility

$0.26

Service Code	NDC 0093-1712-01
Hospital Charge Code	1711483
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

WARFARIN 1 MG TABLET [11664]

Facility

$0.45

Service Code	NDC 0832-1211-01
Hospital Charge Code	1711483
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

WARFARIN 1 MG TABLET [11664]

Facility

$0.26

Service Code	NDC 0093-1712-01
Hospital Charge Code	1711483
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

WARFARIN 1 MG TABLET [11664]

Facility

$0.19

Service Code	NDC 57237-119-01
Hospital Charge Code	1711483
Hospital Revenue Code	259
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

WARFARIN 1 MG TABLET [11664]

Facility

$0.19

Service Code	NDC 57237-119-01
Hospital Charge Code	1711483
Hospital Revenue Code	259
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

WARFARIN 2.5 MG TABLET [8750]

Facility

$0.47

Service Code	NDC 0832-1213-89
Hospital Charge Code	1710796
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

WARFARIN 2.5 MG TABLET [8750]

Facility

$0.39

Service Code	NDC 68084-027-11
Hospital Charge Code	1710796
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

WARFARIN 2.5 MG TABLET [8750]

Facility

$0.47

Service Code	NDC 0832-1213-01
Hospital Charge Code	1710796
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

Know your out-of-pocket cost for care.

All Charges