Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$1.20

Service Code	NDC 69292-522-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$1.70

Service Code	NDC 60687-304-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.36
Rate for Payer: Cash Price	$0.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.36
Rate for Payer: Health Smart Auto/Commercial	$1.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.27

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$1.22

Service Code	NDC 0143-1171-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$1.70

Service Code	NDC 60687-304-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.02
Rate for Payer: Aetna of CA Government/Medicare	$1.02
Rate for Payer: Cash Price	$0.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.36
Rate for Payer: Health Smart Auto/Commercial	$1.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.27

CAPTOPRIL 12.5 MG TABLET [9401]

Facility

$1.70

Service Code	NDC 60687-304-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.02
Rate for Payer: Aetna of CA Government/Medicare	$1.02
Rate for Payer: Cash Price	$0.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.36
Rate for Payer: Health Smart Auto/Commercial	$1.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.27

CAPTOPRIL 25 MG TABLET [9402]

Facility

$1.27

Service Code	NDC 69292-524-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.95

CAPTOPRIL 25 MG TABLET [9402]

Facility

$1.27

Service Code	NDC 69292-524-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.95

CAPTOPRIL 25 MG TABLET [9402]

Facility

$1.84

Service Code	NDC 60687-315-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.10
Rate for Payer: Aetna of CA Government/Medicare	$1.10
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.47
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.38

CAPTOPRIL 25 MG TABLET [9402]

Facility

$1.84

Service Code	NDC 60687-315-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.47
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.47
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.38

CAPTOPRIL 25 MG TABLET [9402]

Facility

$1.84

Service Code	NDC 60687-315-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.47
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.47
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.38

CAPTOPRIL 25 MG TABLET [9402]

Facility

$1.84

Service Code	NDC 60687-315-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.10
Rate for Payer: Aetna of CA Government/Medicare	$1.10
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.47
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.38

CAPTOPRIL ORAL SUSPENSION COMPOUND 1 MG/ML [4080250]

Facility

$0.06

Service Code	NDC 9994-0802-50
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

CAPTOPRIL ORAL SUSPENSION COMPOUND 1 MG/ML [4080250]

Facility

$0.06

Service Code	NDC 9994-0802-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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	$0.03
Rate for Payer: Multiplan Commercial	$0.05

CARBACHOL 0.01 % INTRAOCULAR SOLUTION [19704]

Facility

$37.18

Service Code	NDC 0065-0023-15
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$29.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.31
Rate for Payer: Aetna of CA Government/Medicare	$22.31
Rate for Payer: Cash Price	$20.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.74
Rate for Payer: Health Smart Auto/Commercial	$22.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.31
Rate for Payer: LLUH Dept of Risk Management WC	$20.45
Rate for Payer: Multiplan Commercial	$27.89

CARBACHOL 0.01 % INTRAOCULAR SOLUTION [19704]

Facility

$37.18

Service Code	NDC 0065-0023-15
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$29.74
Rate for Payer: Cash Price	$20.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.74
Rate for Payer: Health Smart Auto/Commercial	$22.31
Rate for Payer: LLUH Dept of Risk Management WC	$20.45
Rate for Payer: Multiplan Commercial	$27.89

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION [111849]

Facility

$0.53

Service Code	NDC 0078-0508-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION [111849]

Facility

$0.53

Service Code	NDC 0078-0508-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.61

Service Code	NDC 0904-3854-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.48

Service Code	NDC 51079-870-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.48

Service Code	NDC 51672-4041-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.61

Service Code	NDC 0904-3854-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.48

Service Code	NDC 51672-4041-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.58

Service Code	NDC 60687-479-11
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	$0.32
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.63

Service Code	NDC 13668-271-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

CARBAMAZEPINE 100 MG CHEWABLE TABLET [1355]

Facility

$0.58

Service Code	NDC 60687-479-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
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

Know your out-of-pocket cost for care.

All Charges