Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CALCIUM GLUCONATE 1 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION [232808]

Facility

$0.15

Service Code	CPT J0613
Hospital Charge Code	NDG232808
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION [225276]

Facility

$0.47

Service Code	CPT J0613
Hospital Charge Code	NDG225276
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION [225276]

Facility

$0.47

Service Code	CPT J0613
Hospital Charge Code	NDG225276
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

CALCIUM GLUCONATE 50 MG/ML (5%) IV [4080945]

Facility

$0.04

Service Code	CPT J0612
Hospital Charge Code	NDG4080945
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: 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 Beech St/Commercial/PHCS	$0.03

CALCIUM GLUCONATE 50 MG/ML (5%) IV [4080945]

Facility

$0.04

Service Code	CPT J0612
Hospital Charge Code	NDG4080945
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

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

Facility

$0.06

Service Code	NDC 9994-0804-24
Hospital Charge Code	NDC4080424
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.05

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

Facility

$0.06

Service Code	NDC 9994-0804-24
Hospital Charge Code	NDC4080424
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: 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 Beech St/Commercial/PHCS	$0.05

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

Facility

$0.65

Service Code	CPT J0612
Hospital Charge Code	1720196
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.49
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	$0.29
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 Beech St/Commercial/PHCS	$0.49

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

Facility

$0.65

Service Code	CPT J0612
Hospital Charge Code	1720196
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.49

CALCIUM GLUCONATE STRIGHT DRUG INFUSION 50 MG/ML 5 % [4080780]

Facility

$0.04

Service Code	CPT J0612
Hospital Charge Code	ERX4080780
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: 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 Beech St/Commercial/PHCS	$0.03

CALCIUM GLUCONATE STRIGHT DRUG INFUSION 50 MG/ML 5 % [4080780]

Facility

$0.04

Service Code	CPT J0612
Hospital Charge Code	ERX4080780
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

CALCIUM POLYCARBOPHIL 625 MG TABLET [11046]

Facility

$0.15

Service Code	NDC 0005-2500-02
Hospital Charge Code	1773060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

CALCIUM POLYCARBOPHIL 625 MG TABLET [11046]

Facility

$0.15

Service Code	NDC 0005-2500-02
Hospital Charge Code	1773060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.07
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 Beech St/Commercial/PHCS	$0.11

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

Facility

$181.79

Service Code	CPT J3490
Hospital Charge Code	1712426
Hospital Revenue Code	636
Min. Negotiated Rate	$99.98
Max. Negotiated Rate	$145.43
Rate for Payer: Cash Price	$81.81
Rate for Payer: Cigna of CA HMO/PPO	$145.43
Rate for Payer: Health Smart Auto/Commercial	$109.07
Rate for Payer: LLUH Dept of Risk Management WC	$99.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$136.34

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

Facility

$160.88

Service Code	CPT J3490
Hospital Charge Code	1711786
Hospital Revenue Code	636
Min. Negotiated Rate	$88.48
Max. Negotiated Rate	$120.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.53
Rate for Payer: Aetna of CA Government/Medicare	$96.53
Rate for Payer: Cash Price	$72.40
Rate for Payer: Health Smart Auto/Commercial	$96.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$96.53
Rate for Payer: LLUH Dept of Risk Management WC	$88.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.66

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

Facility

$181.79

Service Code	CPT J3490
Hospital Charge Code	1712426
Hospital Revenue Code	636
Min. Negotiated Rate	$99.98
Max. Negotiated Rate	$136.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$109.07
Rate for Payer: Aetna of CA Government/Medicare	$109.07
Rate for Payer: Cash Price	$81.81
Rate for Payer: Health Smart Auto/Commercial	$109.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$109.07
Rate for Payer: LLUH Dept of Risk Management WC	$99.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$136.34

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

Facility

$160.88

Service Code	CPT J3490
Hospital Charge Code	1711786
Hospital Revenue Code	636
Min. Negotiated Rate	$88.48
Max. Negotiated Rate	$128.70
Rate for Payer: Cash Price	$72.40
Rate for Payer: Cigna of CA HMO/PPO	$128.70
Rate for Payer: Health Smart Auto/Commercial	$96.53
Rate for Payer: LLUH Dept of Risk Management WC	$88.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.66

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

Facility

$0.09

Service Code	NDC 2390000361
Hospital Charge Code	NDG28132
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: 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 Beech St/Commercial/PHCS	$0.07

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	NDG28132
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	NDG76967A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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: 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 Beech St/Commercial/PHCS	$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	NDG28132
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: 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 Beech St/Commercial/PHCS	$0.07

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

Facility

$0.07

Service Code	NDC 2390000015
Hospital Charge Code	NDG76967A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	NDG76967A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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: 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 Beech St/Commercial/PHCS	$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	NDG28132
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	NDG28132
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: 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 Beech St/Commercial/PHCS	$0.08

Know your out-of-pocket cost for care.

All Charges