Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CABERGOLINE 0.5 MG TABLET [19226]

Facility

$3.75

Service Code	NDC 50742-118-08
Hospital Charge Code	1712340
Hospital Revenue Code	259
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.25
Rate for Payer: Aetna of CA Government/Medicare	$2.25
Rate for Payer: Cash Price	$1.69
Rate for Payer: Health Smart Auto/Commercial	$2.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.81

CABERGOLINE 0.5 MG TABLET [19226]

Facility

$3.75

Service Code	NDC 50742-118-08
Hospital Charge Code	1712340
Hospital Revenue Code	259
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$3.00
Rate for Payer: Cash Price	$1.69
Rate for Payer: Cigna of CA HMO/PPO	$3.00
Rate for Payer: Health Smart Auto/Commercial	$2.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.81

CABERGOLINE 0.5 MG TABLET [19226]

Facility

$2.44

Service Code	NDC 23155-823-73
Hospital Charge Code	1712340
Hospital Revenue Code	259
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.95
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cigna of CA HMO/PPO	$1.95
Rate for Payer: Health Smart Auto/Commercial	$1.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.83

CABERGOLINE 0.5 MG TABLET [19226]

Facility

$2.44

Service Code	NDC 23155-823-73
Hospital Charge Code	1712340
Hospital Revenue Code	259
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.46
Rate for Payer: Aetna of CA Government/Medicare	$1.46
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Smart Auto/Commercial	$1.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.83

CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]

Facility

$3.40

Service Code	NDC 4056512249
Hospital Charge Code	1743674
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.72
Rate for Payer: Cash Price	$1.53
Rate for Payer: Cigna of CA HMO/PPO	$2.72
Rate for Payer: Health Smart Auto/Commercial	$2.04
Rate for Payer: LLUH Dept of Risk Management WC	$1.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.55

CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]

Facility

$3.40

Service Code	NDC 4056512249
Hospital Charge Code	1743674
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.04
Rate for Payer: Aetna of CA Government/Medicare	$2.04
Rate for Payer: Cash Price	$1.53
Rate for Payer: Health Smart Auto/Commercial	$2.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.04
Rate for Payer: LLUH Dept of Risk Management WC	$1.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.55

CAFFEINE 200 MG TABLET [1259]

Facility

$0.11

Service Code	NDC 46122-457-73
Hospital Charge Code	1710902
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

CAFFEINE 200 MG TABLET [1259]

Facility

$0.16

Service Code	NDC 4601701840
Hospital Charge Code	1710902
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

CAFFEINE 200 MG TABLET [1259]

Facility

$0.16

Service Code	NDC 4601701840
Hospital Charge Code	1710902
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
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	$0.07
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 Beech St/Commercial/PHCS	$0.12

CAFFEINE 200 MG TABLET [1259]

Facility

$0.17

Service Code	NDC 4601701816
Hospital Charge Code	1710902
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
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	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

CAFFEINE 200 MG TABLET [1259]

Facility

$0.17

Service Code	NDC 4601701816
Hospital Charge Code	1710902
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	$0.08
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 Beech St/Commercial/PHCS	$0.13

CAFFEINE 200 MG TABLET [1259]

Facility

$0.11

Service Code	NDC 46122-457-73
Hospital Charge Code	1710902
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

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

Facility

$3.26

Service Code	CPT J0706
Hospital Charge Code	NDG77412
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.61
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.24
Rate for Payer: Cigna of CA HMO/PPO	$5.76
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Cigna of CA HMO/PPO	$2.61
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	$1.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

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

Facility

$3.26

Service Code	CPT J0706
Hospital Charge Code	NDG77412
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.96
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 Government/Medicare	$1.96
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cash Price	$3.24
Rate for Payer: Health Smart Auto/Commercial	$1.96
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.96
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: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$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	1715184
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	1715184
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
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	$1.80
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 Beech St/Commercial/PHCS	$3.00

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

Facility

$15.50

Service Code	NDC 63323-406-03
Hospital Charge Code	NDG77411
Hospital Revenue Code	259
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$12.40
Rate for Payer: Cash Price	$6.98
Rate for Payer: Cigna of CA HMO/PPO	$12.40
Rate for Payer: Health Smart Auto/Commercial	$9.30
Rate for Payer: LLUH Dept of Risk Management WC	$8.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.62

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

Facility

$8.00

Service Code	NDC 25021-602-03
Hospital Charge Code	NDG77411
Hospital Revenue Code	259
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.00
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	$3.60
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 Beech St/Commercial/PHCS	$6.00

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

Facility

$8.00

Service Code	NDC 25021-602-03
Hospital Charge Code	NDG77411
Hospital Revenue Code	259
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$6.00

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

Facility

$15.50

Service Code	NDC 63323-406-03
Hospital Charge Code	NDG77411
Hospital Revenue Code	259
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$11.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.30
Rate for Payer: Aetna of CA Government/Medicare	$9.30
Rate for Payer: Cash Price	$6.98
Rate for Payer: Health Smart Auto/Commercial	$9.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.30
Rate for Payer: LLUH Dept of Risk Management WC	$8.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.62

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

Facility

$16.57

Service Code	NDC 0517-2502-01
Hospital Charge Code	1720528
Hospital Revenue Code	250
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$12.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.94
Rate for Payer: Aetna of CA Government/Medicare	$9.94
Rate for Payer: Cash Price	$7.46
Rate for Payer: Health Smart Auto/Commercial	$9.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.94
Rate for Payer: LLUH Dept of Risk Management WC	$9.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.43

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

Facility

$16.57

Service Code	NDC 0517-2502-10
Hospital Charge Code	1720528
Hospital Revenue Code	250
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$13.26
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cigna of CA HMO/PPO	$13.26
Rate for Payer: Health Smart Auto/Commercial	$9.94
Rate for Payer: LLUH Dept of Risk Management WC	$9.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.43

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

Facility

$16.57

Service Code	NDC 0517-2502-10
Hospital Charge Code	1720528
Hospital Revenue Code	250
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$12.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.94
Rate for Payer: Aetna of CA Government/Medicare	$9.94
Rate for Payer: Cash Price	$7.46
Rate for Payer: Health Smart Auto/Commercial	$9.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.94
Rate for Payer: LLUH Dept of Risk Management WC	$9.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.43

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

Facility

$16.57

Service Code	NDC 0517-2502-01
Hospital Charge Code	1720528
Hospital Revenue Code	250
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$13.26
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cigna of CA HMO/PPO	$13.26
Rate for Payer: Health Smart Auto/Commercial	$9.94
Rate for Payer: LLUH Dept of Risk Management WC	$9.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.43

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

Facility

$0.01

Service Code	NDC 0904-2533-21
Hospital Charge Code	NDG78879B
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: 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	$0.01

Know your out-of-pocket cost for care.

All Charges