Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214003147
Hospital Charge Code	1743600
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
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	$0.03

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214063608
Hospital Charge Code	1743600
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
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	$0.03

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.10

Service Code	NDC 7214045231
Hospital Charge Code	1743664
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]

Facility

$0.04

Service Code	NDC 7214063386
Hospital Charge Code	1743600
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

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]

Facility

$3.35

Service Code	NDC 0023-0312-04
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.68
Rate for Payer: Cash Price	$1.51
Rate for Payer: Cigna of CA HMO/PPO	$2.68
Rate for Payer: Health Smart Auto/Commercial	$2.01
Rate for Payer: LLUH Dept of Risk Management WC	$1.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.51

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]

Facility

$2.90

Service Code	NDC 0023-0312-07
Hospital Charge Code	NDG119525
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.32
Rate for Payer: Cash Price	$1.31
Rate for Payer: Cigna of CA HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.18

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]

Facility

$3.35

Service Code	NDC 0023-0312-04
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.01
Rate for Payer: Aetna of CA Government/Medicare	$2.01
Rate for Payer: Cash Price	$1.51
Rate for Payer: Health Smart Auto/Commercial	$2.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.01
Rate for Payer: LLUH Dept of Risk Management WC	$1.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.51

WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]

Facility

$2.90

Service Code	NDC 0023-0312-07
Hospital Charge Code	NDG119525
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.74
Rate for Payer: Aetna of CA Government/Medicare	$1.74
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.18

WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]

Facility

$2.34

Service Code	NDC 1011902239
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]

Facility

$2.34

Service Code	NDC 9999-9022-39
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]

Facility

$2.34

Service Code	NDC 9999-9022-39
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]

Facility

$2.34

Service Code	NDC 1011902239
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]

Facility

$2.40

Service Code	NDC 17478-062-35
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]

Facility

$1.85

Service Code	NDC 0904-6488-38
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$0.83
Rate for Payer: Cigna of CA HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.39

WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]

Facility

$1.85

Service Code	NDC 0904-6488-38
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.11
Rate for Payer: Aetna of CA Government/Medicare	$1.11
Rate for Payer: Cash Price	$0.83
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.39

WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]

Facility

$2.40

Service Code	NDC 17478-062-35
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [119919]

Facility

$2.45

Service Code	NDC 0065-0518-01
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cigna of CA HMO/PPO	$1.96
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [119919]

Facility

$2.45

Service Code	NDC 0065-0518-01
Hospital Charge Code	1740053
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.47
Rate for Payer: Aetna of CA Government/Medicare	$1.47
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT [115913]

Facility

$0.07

Service Code	NDC 4628750704
Hospital Charge Code	1743669
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

WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT [115913]

Facility

$0.07

Service Code	NDC 4628750704
Hospital Charge Code	1743669
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

ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]

Facility

$0.18

Service Code	CPT S0104
Hospital Charge Code	1715069
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	$0.08
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

ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]

Facility

$0.18

Service Code	CPT S0104
Hospital Charge Code	1715069
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
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

ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION [8865]

Facility

$2.84

Service Code	NDC 51754-0102-4
Hospital Charge Code	1721199
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Cash Price	$1.28
Rate for Payer: Cigna of CA HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.13

ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION [8865]

Facility

$2.84

Service Code	NDC 51754-0102-1
Hospital Charge Code	1721199
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.27
Rate for Payer: Cash Price	$1.28
Rate for Payer: Cigna of CA HMO/PPO	$2.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.13

ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION [8865]

Facility

$2.84

Service Code	NDC 51754-0102-4
Hospital Charge Code	1721199
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.70
Rate for Payer: Aetna of CA Government/Medicare	$1.70
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.13

Know your out-of-pocket cost for care.

All Charges