Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CHLORPROMAZINE 10 MG TABLET [1653]

Facility

$0.72

Service Code	NDC 69238-1054-1
Hospital Charge Code	1711161
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]

Facility

$19.86

Service Code	CPT J3230
Hospital Charge Code	1720458
Hospital Revenue Code	636
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$14.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.92
Rate for Payer: Aetna of CA Government/Medicare	$11.92
Rate for Payer: Cash Price	$8.94
Rate for Payer: Health Smart Auto/Commercial	$11.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.92
Rate for Payer: LLUH Dept of Risk Management WC	$10.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.90

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]

Facility

$19.86

Service Code	CPT J3230
Hospital Charge Code	1720458
Hospital Revenue Code	636
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$15.89
Rate for Payer: Cash Price	$8.94
Rate for Payer: Cigna of CA HMO/PPO	$15.89
Rate for Payer: Health Smart Auto/Commercial	$11.92
Rate for Payer: LLUH Dept of Risk Management WC	$10.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.90

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$1.20

Service Code	NDC 0527-2962-37
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.90
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	$0.54
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 Beech St/Commercial/PHCS	$0.90

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$1.02

Service Code	NDC 68462-862-01
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$7.11

Service Code	NDC 60687-430-11
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.27
Rate for Payer: Aetna of CA Government/Medicare	$4.27
Rate for Payer: Cash Price	$3.20
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.33

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$7.11

Service Code	NDC 60687-430-01
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.27
Rate for Payer: Aetna of CA Government/Medicare	$4.27
Rate for Payer: Cash Price	$3.20
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.33

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$1.02

Service Code	NDC 68462-862-01
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$7.11

Service Code	NDC 60687-430-01
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.69
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of CA HMO/PPO	$5.69
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.33

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$1.20

Service Code	NDC 0527-2962-37
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$4.54

Service Code	NDC 0832-0301-00
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.63
Rate for Payer: Cash Price	$2.04
Rate for Payer: Cigna of CA HMO/PPO	$3.63
Rate for Payer: Health Smart Auto/Commercial	$2.72
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.40

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$4.54

Service Code	NDC 0832-0301-00
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.72
Rate for Payer: Aetna of CA Government/Medicare	$2.72
Rate for Payer: Cash Price	$2.04
Rate for Payer: Health Smart Auto/Commercial	$2.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.72
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.40

CHLORPROMAZINE 25 MG TABLET [1656]

Facility

$7.11

Service Code	NDC 60687-430-11
Hospital Charge Code	1711171
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.69
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of CA HMO/PPO	$5.69
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.33

CHLORPROMAZINE 50 MG TABLET [1657]

Facility

$6.46

Service Code	NDC 0832-0302-00
Hospital Charge Code	1710664
Hospital Revenue Code	259
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$5.17
Rate for Payer: Cash Price	$2.91
Rate for Payer: Cigna of CA HMO/PPO	$5.17
Rate for Payer: Health Smart Auto/Commercial	$3.88
Rate for Payer: LLUH Dept of Risk Management WC	$3.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.84

CHLORPROMAZINE 50 MG TABLET [1657]

Facility

$6.46

Service Code	NDC 0832-0302-00
Hospital Charge Code	1710664
Hospital Revenue Code	259
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$4.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.88
Rate for Payer: Aetna of CA Government/Medicare	$3.88
Rate for Payer: Cash Price	$2.91
Rate for Payer: Health Smart Auto/Commercial	$3.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.88
Rate for Payer: LLUH Dept of Risk Management WC	$3.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.84

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-01
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.70

Service Code	NDC 60687-317-11
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.16
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.02

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-95
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-95
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-01
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-20
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 51079-058-20
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-25
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.70

Service Code	NDC 60687-317-11
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.62
Rate for Payer: Aetna of CA Government/Medicare	$1.62
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.02

CHLORTHALIDONE 25 MG TABLET [1661]

Facility

$2.30

Service Code	NDC 60687-317-25
Hospital Charge Code	1710179
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

Know your out-of-pocket cost for care.

All Charges