Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CALCIUM GLUCONATE ORAL SOLUTION (IV FORM) 100 MG/ML [4080424]

Facility

$0.06

Service Code	NDC 9994-0804-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

CALCIUM GLUCONATE STRAIGHT DRUG INFUSION 100 MG/ML 10 % [4080741]

Facility

$0.65

Service Code	HCPCS J0612
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

CALCIUM GLUCONATE STRAIGHT DRUG INFUSION 100 MG/ML 10 % [4080741]

Facility

$0.65

Service Code	HCPCS J0612
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

CALCIUM POLYCARBOPHIL 625 MG TABLET [11046]

Facility

$0.15

Service Code	NDC 0005-2500-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

CALCIUM POLYCARBOPHIL 625 MG TABLET [11046]

Facility

$0.15

Service Code	NDC 0005-2500-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

CALFACTANT 35 MG/ML IN 0.9% SODIUM CHLORIDE INTRATRACHEAL SUSPENSION [23500]

Facility

$211.18

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$116.15
Max. Negotiated Rate	$168.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$112.14
Rate for Payer: Aetna of CA Government/Medicare	$112.14
Rate for Payer: Aetna of CA Government/Medicare	$126.71
Rate for Payer: Cash Price	$102.79
Rate for Payer: Cash Price	$116.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$149.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.94
Rate for Payer: Health Smart Auto/Commercial	$126.71
Rate for Payer: Health Smart Auto/Commercial	$112.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$112.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.71
Rate for Payer: LLUH Dept of Risk Management WC	$102.80
Rate for Payer: LLUH Dept of Risk Management WC	$116.15
Rate for Payer: Multiplan Commercial	$140.18
Rate for Payer: Multiplan Commercial	$158.38

CALFACTANT 35 MG/ML IN 0.9% SODIUM CHLORIDE INTRATRACHEAL SUSPENSION [23500]

Facility

$211.18

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$116.15
Max. Negotiated Rate	$168.94
Rate for Payer: Cash Price	$116.15
Rate for Payer: Cash Price	$102.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$149.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.94
Rate for Payer: Health Smart Auto/Commercial	$112.14
Rate for Payer: Health Smart Auto/Commercial	$126.71
Rate for Payer: LLUH Dept of Risk Management WC	$102.80
Rate for Payer: LLUH Dept of Risk Management WC	$116.15
Rate for Payer: Multiplan Commercial	$158.38
Rate for Payer: Multiplan Commercial	$140.18

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.07

Service Code	NDC 2390000015
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.07

Service Code	NDC 2390000015
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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 Commercial	$0.05

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.09

Service Code	NDC 37000-544-01
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	$0.05
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.07

Service Code	NDC 37000-544-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.09

Service Code	NDC 2390000361
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
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

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.07

Service Code	NDC 37000-544-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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 Commercial	$0.05

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.09

Service Code	NDC 2390000361
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	$0.05
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.10

Service Code	NDC 2390003920
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	$0.06
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.10

Service Code	NDC 2390003920
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
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

CAMPHOR-EUCALYPTUS OIL-MENTHOL 4.8 %-1.2 %-2.6 % TOPICAL OINTMENT [76967]

Facility

$0.09

Service Code	NDC 37000-544-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
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

CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]

Facility

$0.03

Service Code	NDC 46122-573-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$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 Commercial	$0.02

CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION [23063]

Facility

$0.03

Service Code	NDC 46122-573-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]

Facility

$0.12

Service Code	NDC 0024-5150-05
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	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]

Facility

$0.12

Service Code	NDC 0024-5150-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]

Facility

$0.12

Service Code	NDC 0024-5150-06
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	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]

Facility

$0.12

Service Code	NDC 0024-5150-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

CANAGLIFLOZIN 100 MG TABLET [201798]

Facility

$23.94

Service Code	NDC 50458-140-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.17
Max. Negotiated Rate	$19.15
Rate for Payer: Cash Price	$13.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.15
Rate for Payer: Health Smart Auto/Commercial	$14.36
Rate for Payer: LLUH Dept of Risk Management WC	$13.17
Rate for Payer: Multiplan Commercial	$17.95

CANAGLIFLOZIN 100 MG TABLET [201798]

Facility

$23.94

Service Code	NDC 50458-140-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.17
Max. Negotiated Rate	$19.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.36
Rate for Payer: Aetna of CA Government/Medicare	$14.36
Rate for Payer: Cash Price	$13.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.15
Rate for Payer: Health Smart Auto/Commercial	$14.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.36
Rate for Payer: LLUH Dept of Risk Management WC	$13.17
Rate for Payer: Multiplan Commercial	$17.95

Know your out-of-pocket cost for care.

All Charges