Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$1.30

Service Code	NDC 6332369441
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$1.19

Service Code	NDC 6332369030
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$4.79

Service Code	NDC 6332369404
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.83
Rate for Payer: Health Smart Auto/Commercial	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: Multiplan Commercial	$3.59

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$0.26

Service Code	NDC 6332369041
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$0.26

Service Code	NDC 6332369041
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$4.79

Service Code	NDC 6332369404
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$3.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.87
Rate for Payer: Aetna of CA Government/Medicare	$2.87
Rate for Payer: Cash Price	$2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.83
Rate for Payer: Health Smart Auto/Commercial	$2.87
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$2.63
Rate for Payer: Multiplan Commercial	$3.59

ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]

Facility

$1.30

Service Code	NDC 6332369441
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

ACETYLCYSTEINE 600 MG CAPSULE [118614]

Facility

$0.09

Service Code	NDC 7985404097
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

ACETYLCYSTEINE 600 MG CAPSULE [118614]

Facility

$0.09

Service Code	NDC 7985404097
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.07

ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]

Facility

$0.35

Service Code	NDC 9994080415
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]

Facility

$0.35

Service Code	NDC 9994080415
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]

Facility

$3.84

Service Code	NDC 9994080235
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.07
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.88

ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]

Facility

$3.84

Service Code	NDC 9994080235
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.07
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.88

ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]

Facility

$0.58

Service Code	NDC 9994080234
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]

Facility

$0.58

Service Code	NDC 9994080234
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

ACITRETIN 25 MG CAPSULE [13979]

Facility

$18.46

Service Code	NDC 0115175308
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$14.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.08
Rate for Payer: Aetna of CA Government/Medicare	$11.08
Rate for Payer: Cash Price	$8.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.77
Rate for Payer: Health Smart Auto/Commercial	$11.08
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$11.08
Rate for Payer: LLUH Dept of Risk Management WC	$10.15
Rate for Payer: Multiplan Commercial	$13.85

ACITRETIN 25 MG CAPSULE [13979]

Facility

$18.46

Service Code	NDC 0115175308
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$14.77
Rate for Payer: Cash Price	$8.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.77
Rate for Payer: Health Smart Auto/Commercial	$11.08
Rate for Payer: LLUH Dept of Risk Management WC	$10.15
Rate for Payer: Multiplan Commercial	$13.85

ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]

Facility

$0.13

Service Code	NDC 0574052174
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]

Facility

$0.13

Service Code	NDC 0574052174
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]

Facility

$0.10

Service Code	NDC 0574052176
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]

Facility

$0.16

Service Code	NDC 6668920108
Hospital Charge Code	901700029
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]

Facility

$0.10

Service Code	NDC 0574052176
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]

Facility

$0.16

Service Code	NDC 6668920108
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.12

ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]

Facility

$0.20

Service Code	HCPCS J8499
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15
Rate for Payer: Multiplan Commercial	$0.68

ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [8970]

Facility

$0.20

Service Code	HCPCS J8499
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.15
Rate for Payer: Multiplan Commercial	$0.68

Know your out-of-pocket cost for care.

All Charges