Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ADAGRASIB 200 MG TABLET [236395]

Facility

$131.67

Service Code	NDC 80739-812-18
Hospital Charge Code	ERX236395
Hospital Revenue Code	259
Min. Negotiated Rate	$72.42
Max. Negotiated Rate	$105.34
Rate for Payer: Cash Price	$59.25
Rate for Payer: Cigna of CA HMO/PPO	$105.34
Rate for Payer: Health Smart Auto/Commercial	$79.00
Rate for Payer: LLUH Dept of Risk Management WC	$72.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$98.75

ADAGRASIB 200 MG TABLET [236395]

Facility

$131.67

Service Code	NDC 80739-812-18
Hospital Charge Code	ERX236395
Hospital Revenue Code	259
Min. Negotiated Rate	$72.42
Max. Negotiated Rate	$98.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$79.00
Rate for Payer: Aetna of CA Government/Medicare	$79.00
Rate for Payer: Cash Price	$59.25
Rate for Payer: Health Smart Auto/Commercial	$79.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$79.00
Rate for Payer: LLUH Dept of Risk Management WC	$72.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$98.75

ADAPALENE 0.1 % TOPICAL CREAM [21831]

Facility

$6.03

Service Code	NDC 45802-453-84
Hospital Charge Code	NDG21831
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.52
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	$2.71
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 Beech St/Commercial/PHCS	$4.52

ADAPALENE 0.1 % TOPICAL CREAM [21831]

Facility

$6.03

Service Code	NDC 45802-453-84
Hospital Charge Code	NDG21831
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$2.71
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$4.52

ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]

Facility

$3.60

Service Code	CPT J0153
Hospital Charge Code	1720684
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.14
Rate for Payer: Aetna of CA Government/Medicare	$2.14
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$2.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$1.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.08

ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]

Facility

$1.44

Service Code	CPT J0153
Hospital Charge Code	1720684
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA HMO/PPO	$1.15
Rate for Payer: Cigna of CA HMO/PPO	$2.86
Rate for Payer: Cigna of CA HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Health Smart Auto/Commercial	$2.14
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	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$1.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

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

Facility

$1.44

Service Code	CPT J0153
Hospital Charge Code	1720684
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.08

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

Facility

$1.44

Service Code	CPT J0153
Hospital Charge Code	1720684
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cigna of CA HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.08

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

Facility

$5.72

Service Code	CPT J0153
Hospital Charge Code	1720905
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cash Price	$3.49
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna of CA HMO/PPO	$4.09
Rate for Payer: Cigna of CA HMO/PPO	$6.21
Rate for Payer: Cigna of CA HMO/PPO	$4.58
Rate for Payer: Cigna of CA HMO/PPO	$3.66
Rate for Payer: Health Smart Auto/Commercial	$2.74
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: LLUH Dept of Risk Management WC	$2.51
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.29

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

Facility

$4.57

Service Code	CPT J0153
Hospital Charge Code	1720905
Hospital Revenue Code	636
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$3.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.43
Rate for Payer: Aetna of CA Government/Medicare	$4.66
Rate for Payer: Aetna of CA Government/Medicare	$3.43
Rate for Payer: Aetna of CA Government/Medicare	$2.74
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cash Price	$3.49
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cash Price	$2.06
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: Health Smart Auto/Commercial	$2.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.51
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: LLUH Dept of Risk Management WC	$2.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.83

ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]

Facility

$4,490.48

Service Code	CPT J9354
Hospital Charge Code	ERX200177
Hospital Revenue Code	636
Min. Negotiated Rate	$2,469.76
Max. Negotiated Rate	$3,367.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,694.29
Rate for Payer: Aetna of CA Government/Medicare	$2,694.29
Rate for Payer: Cash Price	$2,020.72
Rate for Payer: Health Smart Auto/Commercial	$2,694.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,694.29
Rate for Payer: LLUH Dept of Risk Management WC	$2,469.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,367.86

ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]

Facility

$4,490.48

Service Code	CPT J9354
Hospital Charge Code	ERX200177
Hospital Revenue Code	636
Min. Negotiated Rate	$2,469.76
Max. Negotiated Rate	$3,592.38
Rate for Payer: Cash Price	$2,020.72
Rate for Payer: Cigna of CA HMO/PPO	$3,592.38
Rate for Payer: Health Smart Auto/Commercial	$2,694.29
Rate for Payer: LLUH Dept of Risk Management WC	$2,469.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,367.86

ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]

Facility

$7,184.76

Service Code	CPT J9354
Hospital Charge Code	ERX200178
Hospital Revenue Code	636
Min. Negotiated Rate	$3,951.62
Max. Negotiated Rate	$5,747.81
Rate for Payer: Cash Price	$3,233.14
Rate for Payer: Cigna of CA HMO/PPO	$5,747.81
Rate for Payer: Health Smart Auto/Commercial	$4,310.86
Rate for Payer: LLUH Dept of Risk Management WC	$3,951.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,388.57

ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]

Facility

$7,184.76

Service Code	CPT J9354
Hospital Charge Code	ERX200178
Hospital Revenue Code	636
Min. Negotiated Rate	$3,951.62
Max. Negotiated Rate	$5,388.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4,310.86
Rate for Payer: Aetna of CA Government/Medicare	$4,310.86
Rate for Payer: Cash Price	$3,233.14
Rate for Payer: Health Smart Auto/Commercial	$4,310.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4,310.86
Rate for Payer: LLUH Dept of Risk Management WC	$3,951.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,388.57

AFLIBERCEPT 2 MG/0.05 ML INTRAVITREAL SOLUTION FOR INJECTION [152966]

Facility

$44,400.00

Service Code	CPT J0178
Hospital Charge Code	NDG152966
Hospital Revenue Code	636
Min. Negotiated Rate	$24,420.00
Max. Negotiated Rate	$33,300.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$26,640.00
Rate for Payer: Aetna of CA Government/Medicare	$26,640.00
Rate for Payer: Cash Price	$19,980.00
Rate for Payer: Health Smart Auto/Commercial	$26,640.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$26,640.00
Rate for Payer: LLUH Dept of Risk Management WC	$24,420.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33,300.00

AFLIBERCEPT 2 MG/0.05 ML INTRAVITREAL SOLUTION FOR INJECTION [152966]

Facility

$44,400.00

Service Code	CPT J0178
Hospital Charge Code	NDG152966
Hospital Revenue Code	636
Min. Negotiated Rate	$24,420.00
Max. Negotiated Rate	$35,520.00
Rate for Payer: Cash Price	$19,980.00
Rate for Payer: Cigna of CA HMO/PPO	$35,520.00
Rate for Payer: Health Smart Auto/Commercial	$26,640.00
Rate for Payer: LLUH Dept of Risk Management WC	$24,420.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33,300.00

AGALSIDASE BETA 35 MG INTRAVENOUS SOLUTION [35775]

Facility

$8,685.12

Service Code	CPT J0180
Hospital Charge Code	1755755
Hospital Revenue Code	636
Min. Negotiated Rate	$4,776.82
Max. Negotiated Rate	$6,513.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,211.07
Rate for Payer: Aetna of CA Government/Medicare	$5,211.07
Rate for Payer: Cash Price	$3,908.30
Rate for Payer: Health Smart Auto/Commercial	$5,211.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,211.07
Rate for Payer: LLUH Dept of Risk Management WC	$4,776.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,513.84

AGALSIDASE BETA 35 MG INTRAVENOUS SOLUTION [35775]

Facility

$8,685.12

Service Code	CPT J0180
Hospital Charge Code	1755755
Hospital Revenue Code	636
Min. Negotiated Rate	$4,776.82
Max. Negotiated Rate	$6,948.10
Rate for Payer: Cash Price	$3,908.30
Rate for Payer: Cigna of CA HMO/PPO	$6,948.10
Rate for Payer: Health Smart Auto/Commercial	$5,211.07
Rate for Payer: LLUH Dept of Risk Management WC	$4,776.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,513.84

AGALSIDASE BETA 5 MG INTRAVENOUS SOLUTION [38494]

Facility

$1,240.52

Service Code	CPT J0180
Hospital Charge Code	1755754
Hospital Revenue Code	636
Min. Negotiated Rate	$682.29
Max. Negotiated Rate	$930.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$744.31
Rate for Payer: Aetna of CA Government/Medicare	$744.31
Rate for Payer: Cash Price	$558.23
Rate for Payer: Health Smart Auto/Commercial	$744.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$744.31
Rate for Payer: LLUH Dept of Risk Management WC	$682.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$930.39

AGALSIDASE BETA 5 MG INTRAVENOUS SOLUTION [38494]

Facility

$1,240.52

Service Code	CPT J0180
Hospital Charge Code	1755754
Hospital Revenue Code	636
Min. Negotiated Rate	$682.29
Max. Negotiated Rate	$992.42
Rate for Payer: Cash Price	$558.23
Rate for Payer: Cigna of CA HMO/PPO	$992.42
Rate for Payer: Health Smart Auto/Commercial	$744.31
Rate for Payer: LLUH Dept of Risk Management WC	$682.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$930.39

AGAR (BULK) 100 % POWDER [40822641]

Facility

$0.17

Service Code	NDC 9999-9226-41
Hospital Charge Code	1713148
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	$0.08
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 Beech St/Commercial/PHCS	$0.13

AGAR (BULK) 100 % POWDER [40822641]

Facility

$0.17

Service Code	NDC 9999-9226-41
Hospital Charge Code	1713148
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.13

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$35.85

Service Code	NDC 72205-051-08
Hospital Charge Code	1712227
Hospital Revenue Code	259
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$28.68
Rate for Payer: Cash Price	$16.13
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$26.89

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$36.00

Service Code	NDC 31722-935-02
Hospital Charge Code	1712227
Hospital Revenue Code	259
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$27.00
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	$16.20
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 Beech St/Commercial/PHCS	$27.00

ALBENDAZOLE 200 MG TABLET [8979]

Facility

$35.85

Service Code	NDC 72205-051-08
Hospital Charge Code	1712227
Hospital Revenue Code	259
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$26.89
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	$16.13
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 Beech St/Commercial/PHCS	$26.89

Know your out-of-pocket cost for care.

All Charges