Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

METHADONE 10 MG/ML INTRAVENOUS SYRINGE [153564]

Facility

$21.60

Service Code	HCPCS J1230
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$17.28
Rate for Payer: Cash Price	$11.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.28
Rate for Payer: Health Smart Auto/Commercial	$12.96
Rate for Payer: LLUH Dept of Risk Management WC	$11.88
Rate for Payer: Multiplan Commercial	$16.20

METHADONE 10 MG/ML ORAL CONCENTRATE [15996]

Facility

$0.09

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
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	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
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 Commercial	$0.07

METHADONE 10 MG/ML ORAL CONCENTRATE [15996]

Facility

$0.09

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.07

METHADONE 10 MG TABLET [4953]

Facility

$0.42

Service Code	HCPCS S0109
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$0.23
Rate for Payer: Multiplan Commercial	$0.41
Rate for Payer: Multiplan Commercial	$0.41

METHADONE 10 MG TABLET [4953]

Facility

$0.30

Service Code	HCPCS S0109
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$0.41
Rate for Payer: Multiplan Commercial	$0.41
Rate for Payer: Multiplan Commercial	$0.23

METHADONE 1 MG/ML ORAL SOLN UD [4080790]

Facility

$0.08

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
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	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

METHADONE 1 MG/ML ORAL SOLN UD [4080790]

Facility

$0.08

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
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	$0.04
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

METHADONE 5 MG/5 ML ORAL SOLUTION [4952]

Facility

$0.08

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
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: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.06
Rate for Payer: Multiplan Commercial	$0.44

METHADONE 5 MG/5 ML ORAL SOLUTION [4952]

Facility

$0.59

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
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: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.35
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Commercial	$0.06

METHADONE 5 MG TABLET [4954]

Facility

$0.48

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Multiplan Commercial	$0.36

METHADONE 5 MG TABLET [4954]

Facility

$0.35

Service Code	HCPCS S0109
Hospital Charge Code	901700032
Hospital Revenue Code	636
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36
Rate for Payer: Multiplan Commercial	$0.26

METHAZOLAMIDE 50 MG TABLET [4962]

Facility

$3.74

Service Code	NDC 62559-241-01
Hospital Charge Code	901700030
Hospital Revenue Code	259
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.99
Rate for Payer: Cash Price	$2.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.99
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.06
Rate for Payer: Multiplan Commercial	$2.81

METHAZOLAMIDE 50 MG TABLET [4962]

Facility

$3.74

Service Code	NDC 62559-241-01
Hospital Charge Code	901700030
Hospital Revenue Code	259
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.24
Rate for Payer: Aetna of CA Government/Medicare	$2.24
Rate for Payer: Cash Price	$2.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.99
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.06
Rate for Payer: Multiplan Commercial	$2.81

METHENAMINE HIPPURATE 1 GRAM TABLET [10549]

Facility

$2.96

Service Code	NDC 60687-694-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.37
Rate for Payer: Cash Price	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.37
Rate for Payer: Health Smart Auto/Commercial	$1.78
Rate for Payer: LLUH Dept of Risk Management WC	$1.63
Rate for Payer: Multiplan Commercial	$2.22

METHENAMINE HIPPURATE 1 GRAM TABLET [10549]

Facility

$0.96

Service Code	NDC 65862-782-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

METHENAMINE HIPPURATE 1 GRAM TABLET [10549]

Facility

$2.96

Service Code	NDC 60687-694-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.78
Rate for Payer: Aetna of CA Government/Medicare	$1.78
Rate for Payer: Cash Price	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.37
Rate for Payer: Health Smart Auto/Commercial	$1.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.78
Rate for Payer: LLUH Dept of Risk Management WC	$1.63
Rate for Payer: Multiplan Commercial	$2.22

METHENAMINE HIPPURATE 1 GRAM TABLET [10549]

Facility

$2.96

Service Code	NDC 60687-694-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.37
Rate for Payer: Cash Price	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.37
Rate for Payer: Health Smart Auto/Commercial	$1.78
Rate for Payer: LLUH Dept of Risk Management WC	$1.63
Rate for Payer: Multiplan Commercial	$2.22

METHENAMINE HIPPURATE 1 GRAM TABLET [10549]

Facility

$2.96

Service Code	NDC 60687-694-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.78
Rate for Payer: Aetna of CA Government/Medicare	$1.78
Rate for Payer: Cash Price	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.37
Rate for Payer: Health Smart Auto/Commercial	$1.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.78
Rate for Payer: LLUH Dept of Risk Management WC	$1.63
Rate for Payer: Multiplan Commercial	$2.22

METHENAMINE HIPPURATE 1 GRAM TABLET [10549]

Facility

$0.96

Service Code	NDC 65862-782-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

METHENAMINE MANDELATE 1 GRAM TABLET [4966]

Facility

$3.60

Service Code	NDC 42799-106-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
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 Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

METHENAMINE MANDELATE 1 GRAM TABLET [4966]

Facility

$3.60

Service Code	NDC 42799-106-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

METHENAMINE MAND-SOD BIPHOS 500 MG-500 MG TABLET [10550]

Facility

$0.58

Service Code	NDC 0486-1114-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

METHENAMINE MAND-SOD BIPHOS 500 MG-500 MG TABLET [10550]

Facility

$0.58

Service Code	NDC 0486-1114-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

METHIMAZOLE 10 MG TABLET [10552]

Facility

$0.31

Service Code	NDC 23155-071-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

METHIMAZOLE 10 MG TABLET [10552]

Facility

$0.50

Service Code	NDC 64380-213-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

Know your out-of-pocket cost for care.

All Charges