Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]

Facility

$1.06

Service Code	NDC 70010-044-01
Hospital Charge Code	ERX104993
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]

Facility

$1.08

Service Code	NDC 42195-955-10
Hospital Charge Code	ERX104993
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]

Facility

$1.08

Service Code	NDC 42195-955-10
Hospital Charge Code	ERX104993
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE [8922]

Facility

$1.31

Service Code	NDC 0591-3219-01
Hospital Charge Code	1730054
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE [8922]

Facility

$1.31

Service Code	NDC 0591-3219-01
Hospital Charge Code	1730054
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

BUTORPHANOL 10 MG/ML NASAL SPRAY [9335]

Facility

$27.07

Service Code	NDC 60505-0813-1
Hospital Charge Code	1740276
Hospital Revenue Code	259
Min. Negotiated Rate	$14.89
Max. Negotiated Rate	$21.66
Rate for Payer: Cash Price	$12.18
Rate for Payer: Cigna of CA HMO/PPO	$21.66
Rate for Payer: Health Smart Auto/Commercial	$16.24
Rate for Payer: LLUH Dept of Risk Management WC	$14.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.30

BUTORPHANOL 10 MG/ML NASAL SPRAY [9335]

Facility

$27.07

Service Code	NDC 60505-0813-1
Hospital Charge Code	1740276
Hospital Revenue Code	259
Min. Negotiated Rate	$14.89
Max. Negotiated Rate	$20.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.24
Rate for Payer: Aetna of CA Government/Medicare	$16.24
Rate for Payer: Cash Price	$12.18
Rate for Payer: Health Smart Auto/Commercial	$16.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.24
Rate for Payer: LLUH Dept of Risk Management WC	$14.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.30

BUTORPHANOL 1 MG/ML INJECTION SOLUTION [9333]

Facility

$7.36

Service Code	CPT J0595
Hospital Charge Code	1720353
Hospital Revenue Code	636
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$5.89
Rate for Payer: Cash Price	$3.31
Rate for Payer: Cigna of CA HMO/PPO	$5.89
Rate for Payer: Health Smart Auto/Commercial	$4.42
Rate for Payer: LLUH Dept of Risk Management WC	$4.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.52

BUTORPHANOL 1 MG/ML INJECTION SOLUTION [9333]

Facility

$7.36

Service Code	CPT J0595
Hospital Charge Code	1720353
Hospital Revenue Code	636
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$5.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.42
Rate for Payer: Aetna of CA Government/Medicare	$4.42
Rate for Payer: Cash Price	$3.31
Rate for Payer: Health Smart Auto/Commercial	$4.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.42
Rate for Payer: LLUH Dept of Risk Management WC	$4.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.52

BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]

Facility

$6.34

Service Code	CPT J0595
Hospital Charge Code	1720575
Hospital Revenue Code	636
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$4.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.80
Rate for Payer: Aetna of CA Government/Medicare	$3.80
Rate for Payer: Cash Price	$2.85
Rate for Payer: Health Smart Auto/Commercial	$3.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.80
Rate for Payer: LLUH Dept of Risk Management WC	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.76

BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]

Facility

$6.34

Service Code	CPT J0595
Hospital Charge Code	1720575
Hospital Revenue Code	636
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$5.07
Rate for Payer: Cash Price	$2.85
Rate for Payer: Cigna of CA HMO/PPO	$5.07
Rate for Payer: Health Smart Auto/Commercial	$3.80
Rate for Payer: LLUH Dept of Risk Management WC	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.76

BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]

Facility

$3.60

Service Code	CPT J0595
Hospital Charge Code	1720351
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cigna of CA HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]

Facility

$3.60

Service Code	CPT J0595
Hospital Charge Code	1720351
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

BUTT PASTE OINT (LLUMC) [4080617]

Facility

$15.00

Service Code	NDC 9994-0806-17
Hospital Charge Code	1743709
Hospital Revenue Code	259
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

BUTT PASTE OINT (LLUMC) [4080617]

Facility

$15.00

Service Code	NDC 9994-0806-17
Hospital Charge Code	1743709
Hospital Revenue Code	259
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT [192162]

Facility

$4,344.83

Service Code	CPT J0597
Hospital Charge Code	ERX192145
Hospital Revenue Code	636
Min. Negotiated Rate	$2,389.66
Max. Negotiated Rate	$3,475.86
Rate for Payer: Cash Price	$1,955.17
Rate for Payer: Cigna of CA HMO/PPO	$3,475.86
Rate for Payer: Health Smart Auto/Commercial	$2,606.90
Rate for Payer: LLUH Dept of Risk Management WC	$2,389.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,258.62

C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT [192162]

Facility

$4,344.83

Service Code	CPT J0597
Hospital Charge Code	ERX192145
Hospital Revenue Code	636
Min. Negotiated Rate	$2,389.66
Max. Negotiated Rate	$3,258.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,606.90
Rate for Payer: Aetna of CA Government/Medicare	$2,606.90
Rate for Payer: Cash Price	$1,955.17
Rate for Payer: Health Smart Auto/Commercial	$2,606.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,606.90
Rate for Payer: LLUH Dept of Risk Management WC	$2,389.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,258.62

C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION [196347]

Facility

$4,344.83

Service Code	CPT J0597
Hospital Charge Code	ERX196347
Hospital Revenue Code	636
Min. Negotiated Rate	$2,389.66
Max. Negotiated Rate	$3,475.86
Rate for Payer: Cash Price	$1,955.17
Rate for Payer: Cigna of CA HMO/PPO	$3,475.86
Rate for Payer: Health Smart Auto/Commercial	$2,606.90
Rate for Payer: LLUH Dept of Risk Management WC	$2,389.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,258.62

C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION [196347]

Facility

$4,344.83

Service Code	CPT J0597
Hospital Charge Code	ERX196347
Hospital Revenue Code	636
Min. Negotiated Rate	$2,389.66
Max. Negotiated Rate	$3,258.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,606.90
Rate for Payer: Aetna of CA Government/Medicare	$2,606.90
Rate for Payer: Cash Price	$1,955.17
Rate for Payer: Health Smart Auto/Commercial	$2,606.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,606.90
Rate for Payer: LLUH Dept of Risk Management WC	$2,389.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,258.62

C1 ESTERASE INHIBITOR, RECOMBINANT 2,100 UNIT INTRAVENOUS SOLUTION [207371]

Facility

$8,724.00

Service Code	CPT J0596
Hospital Charge Code	ERX207371
Hospital Revenue Code	636
Min. Negotiated Rate	$4,798.20
Max. Negotiated Rate	$6,979.20
Rate for Payer: Cash Price	$3,925.80
Rate for Payer: Cigna of CA HMO/PPO	$6,979.20
Rate for Payer: Health Smart Auto/Commercial	$5,234.40
Rate for Payer: LLUH Dept of Risk Management WC	$4,798.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,543.00

C1 ESTERASE INHIBITOR, RECOMBINANT 2,100 UNIT INTRAVENOUS SOLUTION [207371]

Facility

$8,724.00

Service Code	CPT J0596
Hospital Charge Code	ERX207371
Hospital Revenue Code	636
Min. Negotiated Rate	$4,798.20
Max. Negotiated Rate	$6,543.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,234.40
Rate for Payer: Aetna of CA Government/Medicare	$5,234.40
Rate for Payer: Cash Price	$3,925.80
Rate for Payer: Health Smart Auto/Commercial	$5,234.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,234.40
Rate for Payer: LLUH Dept of Risk Management WC	$4,798.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,543.00

CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION [105644]

Facility

$10,772.15

Service Code	CPT J9043
Hospital Charge Code	1755729
Hospital Revenue Code	636
Min. Negotiated Rate	$5,924.68
Max. Negotiated Rate	$8,079.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6,463.29
Rate for Payer: Aetna of CA Government/Medicare	$6,463.29
Rate for Payer: Cash Price	$4,847.47
Rate for Payer: Health Smart Auto/Commercial	$6,463.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6,463.29
Rate for Payer: LLUH Dept of Risk Management WC	$5,924.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8,079.11

CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION [105644]

Facility

$10,772.15

Service Code	CPT J9043
Hospital Charge Code	1755729
Hospital Revenue Code	636
Min. Negotiated Rate	$5,924.68
Max. Negotiated Rate	$8,617.72
Rate for Payer: Cash Price	$4,847.47
Rate for Payer: Cigna of CA HMO/PPO	$8,617.72
Rate for Payer: Health Smart Auto/Commercial	$6,463.29
Rate for Payer: LLUH Dept of Risk Management WC	$5,924.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8,079.11

CABERGOLINE 0.25 MG 1/2 TABLET [4081952]

Facility

$5.59

Service Code	NDC 9994-0819-52
Hospital Charge Code	ERX4081952
Hospital Revenue Code	259
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$4.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.35
Rate for Payer: Aetna of CA Government/Medicare	$3.35
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Smart Auto/Commercial	$3.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.35
Rate for Payer: LLUH Dept of Risk Management WC	$3.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.19

CABERGOLINE 0.25 MG 1/2 TABLET [4081952]

Facility

$5.59

Service Code	NDC 9994-0819-52
Hospital Charge Code	ERX4081952
Hospital Revenue Code	259
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$4.47
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cigna of CA HMO/PPO	$4.47
Rate for Payer: Health Smart Auto/Commercial	$3.35
Rate for Payer: LLUH Dept of Risk Management WC	$3.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.19

Know your out-of-pocket cost for care.

All Charges