Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]

Facility

$1.35

Service Code	HCPCS J0133
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.08
Rate for Payer: Cash Price	$0.74
Rate for Payer: Cash Price	$1.16
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.57
Rate for Payer: Multiplan Commercial	$1.35
Rate for Payer: Multiplan Commercial	$1.01

ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]

Facility

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$0.81
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.26
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cash Price	$0.74
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.35
Rate for Payer: Multiplan Commercial	$1.01
Rate for Payer: Multiplan Commercial	$1.57

ADAGRASIB 200 MG TABLET [236395]

Facility

$150.62

Service Code	NDC 80739-812-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$82.84
Max. Negotiated Rate	$120.50
Rate for Payer: Cash Price	$82.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.50
Rate for Payer: Health Smart Auto/Commercial	$90.37
Rate for Payer: LLUH Dept of Risk Management WC	$82.84
Rate for Payer: Multiplan Commercial	$112.97

ADAGRASIB 200 MG TABLET [236395]

Facility

$150.62

Service Code	NDC 80739-812-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$82.84
Max. Negotiated Rate	$120.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.37
Rate for Payer: Aetna of CA Government/Medicare	$90.37
Rate for Payer: Cash Price	$82.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.50
Rate for Payer: Health Smart Auto/Commercial	$90.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.37
Rate for Payer: LLUH Dept of Risk Management WC	$82.84
Rate for Payer: Multiplan Commercial	$112.97

ADAPALENE 0.1 % TOPICAL CREAM [21831]

Facility

$6.03

Service Code	NDC 45802-453-84
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.52

ADAPALENE 0.1 % TOPICAL CREAM [21831]

Facility

$6.03

Service Code	NDC 45802-453-84
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.62
Rate for Payer: Aetna of CA Government/Medicare	$3.62
Rate for Payer: Cash Price	$3.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.52

ADENOSINE 300 MCG/ML KIT (NICU) IN NS [4080614]

Facility

$7.20

Service Code	NDC 9994-0806-14
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Commercial	$5.40

ADENOSINE 300 MCG/ML KIT (NICU) IN NS [4080614]

Facility

$7.20

Service Code	NDC 9994-0806-14
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Commercial	$5.40

ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]

Facility

$3.60

Service Code	HCPCS J0153
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.94
Rate for Payer: Aetna of CA Government/Medicare	$3.94
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$3.61
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.26
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.61
Rate for Payer: Multiplan Commercial	$4.93
Rate for Payer: Multiplan Commercial	$2.70

ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]

Facility

$6.57

Service Code	HCPCS J0153
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$5.26
Rate for Payer: Cash Price	$3.61
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.26
Rate for Payer: Health Smart Auto/Commercial	$3.94
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.61
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$4.93

ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]

Facility

$6.57

Service Code	HCPCS J0153
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$5.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.94
Rate for Payer: Aetna of CA Government/Medicare	$3.94
Rate for Payer: Cash Price	$3.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.26
Rate for Payer: Health Smart Auto/Commercial	$3.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.94
Rate for Payer: LLUH Dept of Risk Management WC	$3.61
Rate for Payer: Multiplan Commercial	$4.93

ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]

Facility

$6.57

Service Code	HCPCS J0153
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$5.26
Rate for Payer: Cash Price	$3.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.26
Rate for Payer: Health Smart Auto/Commercial	$3.94
Rate for Payer: LLUH Dept of Risk Management WC	$3.61
Rate for Payer: Multiplan Commercial	$4.93

ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]

Facility

$5.72

Service Code	HCPCS J0153
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.43
Rate for Payer: Aetna of CA Government/Medicare	$3.43
Rate for Payer: Cash Price	$3.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Commercial	$4.29

ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]

Facility

$5.72

Service Code	HCPCS J0153
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$3.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Commercial	$4.29

ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]

Facility

$0.01

Service Code	NDC 58160-829-03
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]

Facility

$0.01

Service Code	NDC 58160-829-03
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

AGAR (BULK) 100 % POWDER [40822641]

Facility

$0.17

Service Code	NDC 9999-9226-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
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	$0.14
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	$0.13

AGAR (BULK) 100 % POWDER [40822641]

Facility

$0.17

Service Code	NDC 9999-9226-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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	$0.13

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$48.00

Service Code	NDC 43598-452-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$38.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.80
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Cash Price	$26.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: Multiplan Commercial	$36.00

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$36.00

Service Code	NDC 31722-935-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$35.85

Service Code	NDC 72205-051-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$28.68
Rate for Payer: Cash Price	$19.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.68
Rate for Payer: Health Smart Auto/Commercial	$21.51
Rate for Payer: LLUH Dept of Risk Management WC	$19.72
Rate for Payer: Multiplan Commercial	$26.89

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$35.85

Service Code	NDC 72205-051-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$28.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.51
Rate for Payer: Aetna of CA Government/Medicare	$21.51
Rate for Payer: Cash Price	$19.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.68
Rate for Payer: Health Smart Auto/Commercial	$21.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.51
Rate for Payer: LLUH Dept of Risk Management WC	$19.72
Rate for Payer: Multiplan Commercial	$26.89

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$36.00

Service Code	NDC 31722-935-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$48.00

Service Code	NDC 43598-452-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$38.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: Multiplan Commercial	$36.00

ALBUMIN, HUMAN 25% CONTINUOUS INTRAVENOUS SOLUTION [4088981]

Facility

$1.12

Service Code	HCPCS P9047
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cash Price	$0.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$0.84
Rate for Payer: Multiplan Commercial	$1.04

Know your out-of-pocket cost for care.

All Charges