Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE [38321]

Facility

$0.44

Service Code	NDC 0023-4554-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [27992]

Facility

$0.69

Service Code	NDC 0023-9205-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [27992]

Facility

$0.69

Service Code	NDC 0023-9205-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

CARFILZOMIB 10 MG INTRAVENOUS SOLUTION [222456]

Facility

$707.44

Service Code	HCPCS J9047
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$389.09
Max. Negotiated Rate	$565.95
Rate for Payer: Cash Price	$389.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$565.95
Rate for Payer: Health Smart Auto/Commercial	$424.46
Rate for Payer: LLUH Dept of Risk Management WC	$389.09
Rate for Payer: Multiplan Commercial	$530.58

CARFILZOMIB 10 MG INTRAVENOUS SOLUTION [222456]

Facility

$707.44

Service Code	HCPCS J9047
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$389.09
Max. Negotiated Rate	$565.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$424.46
Rate for Payer: Aetna of CA Government/Medicare	$424.46
Rate for Payer: Cash Price	$389.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$565.95
Rate for Payer: Health Smart Auto/Commercial	$424.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$424.46
Rate for Payer: LLUH Dept of Risk Management WC	$389.09
Rate for Payer: Multiplan Commercial	$530.58

CARISOPRODOL 350 MG TABLET [1395]

Facility

$0.14

Service Code	NDC 50228-109-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

CARISOPRODOL 350 MG TABLET [1395]

Facility

$0.08

Service Code	NDC 69584-111-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

CARISOPRODOL 350 MG TABLET [1395]

Facility

$0.14

Service Code	NDC 50228-109-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

CARISOPRODOL 350 MG TABLET [1395]

Facility

$0.08

Service Code	NDC 69584-111-10
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	$0.05
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	$0.06
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	$0.04
Rate for Payer: Multiplan Commercial	$0.06

CARMUSTINE 100 MG INTRAVENOUS SOLUTION [28911]

Facility

$648.00

Service Code	HCPCS J9050
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$356.40
Max. Negotiated Rate	$518.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$388.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$252.72
Rate for Payer: Aetna of CA Government/Medicare	$252.72
Rate for Payer: Aetna of CA Government/Medicare	$388.80
Rate for Payer: Cash Price	$231.66
Rate for Payer: Cash Price	$356.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$518.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$336.96
Rate for Payer: Health Smart Auto/Commercial	$388.80
Rate for Payer: Health Smart Auto/Commercial	$252.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$252.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$388.80
Rate for Payer: LLUH Dept of Risk Management WC	$231.66
Rate for Payer: LLUH Dept of Risk Management WC	$356.40
Rate for Payer: Multiplan Commercial	$486.00
Rate for Payer: Multiplan Commercial	$315.90

CARMUSTINE 100 MG INTRAVENOUS SOLUTION [28911]

Facility

$421.20

Service Code	HCPCS J9050
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$231.66
Max. Negotiated Rate	$336.96
Rate for Payer: Cash Price	$231.66
Rate for Payer: Cash Price	$356.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$518.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$336.96
Rate for Payer: Health Smart Auto/Commercial	$252.72
Rate for Payer: Health Smart Auto/Commercial	$388.80
Rate for Payer: LLUH Dept of Risk Management WC	$231.66
Rate for Payer: LLUH Dept of Risk Management WC	$356.40
Rate for Payer: Multiplan Commercial	$315.90
Rate for Payer: Multiplan Commercial	$486.00

CARMUSTINE 50 MG INTRAVENOUS SOLUTION [234861]

Facility

$147.00

Service Code	NDC 16729-545-63
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$117.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$88.20
Rate for Payer: Aetna of CA Government/Medicare	$88.20
Rate for Payer: Cash Price	$80.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.60
Rate for Payer: Health Smart Auto/Commercial	$88.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$88.20
Rate for Payer: LLUH Dept of Risk Management WC	$80.85
Rate for Payer: Multiplan Commercial	$110.25

CARMUSTINE 50 MG INTRAVENOUS SOLUTION [234861]

Facility

$147.00

Service Code	NDC 16729-545-63
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$117.60
Rate for Payer: Cash Price	$80.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.60
Rate for Payer: Health Smart Auto/Commercial	$88.20
Rate for Payer: LLUH Dept of Risk Management WC	$80.85
Rate for Payer: Multiplan Commercial	$110.25

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.06

Service Code	NDC 65862-144-01
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.06

Service Code	NDC 65862-144-01
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.06

Service Code	NDC 68001-151-00
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.07

Service Code	NDC 0093-7295-01
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.16

Service Code	NDC 51079-931-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.06

Service Code	NDC 68382-094-01
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.16

Service Code	NDC 51079-931-20
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	$0.09
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.06

Service Code	NDC 68001-151-00
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.16

Service Code	NDC 51079-931-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.16

Service Code	NDC 51079-931-01
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	$0.09
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.07

Service Code	NDC 0093-7295-01
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

CARVEDILOL 12.5 MG TABLET [15749]

Facility

$0.10

Service Code	NDC 0904-6302-61
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 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

Know your out-of-pocket cost for care.

All Charges