Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

METHOHEXITAL 100 MG/10 ML (10 MG/ML) IN STERILE WATER (PF) IV SYRINGE [153565]

Facility

$7.48

Service Code	NDC 70092-1310-46
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$4.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.98
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.11
Rate for Payer: Multiplan Commercial	$5.61

METHOHEXITAL 100 MG/10 ML (10 MG/ML) IN STERILE WATER (PF) IV SYRINGE [153565]

Facility

$7.48

Service Code	NDC 70092-1310-46
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$5.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.49
Rate for Payer: Aetna of CA Government/Medicare	$4.49
Rate for Payer: Cash Price	$4.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.98
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.11
Rate for Payer: Multiplan Commercial	$5.61

METHOHEXITAL 500 MG SOLUTION FOR INJECTION [70545]

Facility

$133.84

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$73.61
Max. Negotiated Rate	$107.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$80.30
Rate for Payer: Aetna of CA Government/Medicare	$80.30
Rate for Payer: Cash Price	$73.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$107.07
Rate for Payer: Health Smart Auto/Commercial	$80.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$80.30
Rate for Payer: LLUH Dept of Risk Management WC	$73.61
Rate for Payer: Multiplan Commercial	$100.38

METHOHEXITAL 500 MG SOLUTION FOR INJECTION [70545]

Facility

$133.84

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$73.61
Max. Negotiated Rate	$107.07
Rate for Payer: Cash Price	$73.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$107.07
Rate for Payer: Health Smart Auto/Commercial	$80.30
Rate for Payer: LLUH Dept of Risk Management WC	$73.61
Rate for Payer: Multiplan Commercial	$100.38

METHOTREXATE ORAL SUSP IV FORM COMPOUND 2 MG/ML [4080299]

Facility

$0.81

Service Code	NDC 9994-0802-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

METHOTREXATE ORAL SUSP IV FORM COMPOUND 2 MG/ML [4080299]

Facility

$0.81

Service Code	NDC 9994-0802-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

METHOTREXATE SODIUM 1.25 MG 1/2 TABLET [4081484]

Facility

$2.83

Service Code	HCPCS J8610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Commercial	$2.12

METHOTREXATE SODIUM 1.25 MG 1/2 TABLET [4081484]

Facility

$2.83

Service Code	HCPCS J8610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.70
Rate for Payer: Aetna of CA Government/Medicare	$1.70
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Commercial	$2.12

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]

Facility

$4.03

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.62
Rate for Payer: Aetna of CA Government/Medicare	$2.42
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$2.62
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$1.75
Rate for Payer: Cash Price	$2.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.49
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$2.38
Rate for Payer: Multiplan Commercial	$3.02
Rate for Payer: Multiplan Commercial	$3.27

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]

Facility

$4.03

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.22
Rate for Payer: Cash Price	$2.22
Rate for Payer: Cash Price	$1.75
Rate for Payer: Cash Price	$2.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.22
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$3.02
Rate for Payer: Multiplan Commercial	$2.38
Rate for Payer: Multiplan Commercial	$3.27

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION WRAP. (FOR CNR ONLY) [4081565]

Facility

$1.00

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION WRAP. (FOR CNR ONLY) [4081565]

Facility

$1.00

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

METHOTREXATE SODIUM 2.5 MG TABLET [4973]

Facility

$3.32

Service Code	HCPCS J8610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Commercial	$0.50
Rate for Payer: Multiplan Commercial	$2.49

METHOTREXATE SODIUM 2.5 MG TABLET [4973]

Facility

$3.32

Service Code	HCPCS J8610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$1.99
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Commercial	$0.50
Rate for Payer: Multiplan Commercial	$2.49

METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION [4975]

Facility

$76.32

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$61.06
Rate for Payer: Cash Price	$41.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$61.06
Rate for Payer: Health Smart Auto/Commercial	$45.79
Rate for Payer: LLUH Dept of Risk Management WC	$41.98
Rate for Payer: Multiplan Commercial	$57.24

METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION [4975]

Facility

$76.32

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$61.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.79
Rate for Payer: Aetna of CA Government/Medicare	$45.79
Rate for Payer: Cash Price	$41.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$61.06
Rate for Payer: Health Smart Auto/Commercial	$45.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.79
Rate for Payer: LLUH Dept of Risk Management WC	$41.98
Rate for Payer: Multiplan Commercial	$57.24

METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION [96981]

Facility

$2.54

Service Code	HCPCS J9255
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.52
Rate for Payer: Aetna of CA Government/Medicare	$1.52
Rate for Payer: Cash Price	$1.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.03
Rate for Payer: Health Smart Auto/Commercial	$1.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.40
Rate for Payer: Multiplan Commercial	$1.91

METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION [96981]

Facility

$2.54

Service Code	HCPCS J9255
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.03
Rate for Payer: Cash Price	$1.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.03
Rate for Payer: Health Smart Auto/Commercial	$1.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.40
Rate for Payer: Multiplan Commercial	$1.91

METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION [96981]

Facility

$1.10

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cash Price	$3.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.97
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Health Smart Auto/Commercial	$3.73
Rate for Payer: LLUH Dept of Risk Management WC	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Commercial	$4.66

METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION [96981]

Facility

$1.10

Service Code	HCPCS J9260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.73
Rate for Payer: Aetna of CA Government/Medicare	$3.73
Rate for Payer: Aetna of CA Government/Medicare	$0.66
Rate for Payer: Cash Price	$3.42
Rate for Payer: Cash Price	$0.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.97
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Health Smart Auto/Commercial	$3.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.42
Rate for Payer: Multiplan Commercial	$0.83
Rate for Payer: Multiplan Commercial	$4.66

METHOXSALEN 20 MCG/ML INJECTION SOLUTION [24933]

Facility

$75.72

Service Code	NDC 64067-216-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$60.58
Rate for Payer: Cash Price	$41.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.58
Rate for Payer: Health Smart Auto/Commercial	$45.43
Rate for Payer: LLUH Dept of Risk Management WC	$41.65
Rate for Payer: Multiplan Commercial	$56.79

METHOXSALEN 20 MCG/ML INJECTION SOLUTION [24933]

Facility

$75.72

Service Code	NDC 64067-216-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$60.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.43
Rate for Payer: Aetna of CA Government/Medicare	$45.43
Rate for Payer: Cash Price	$41.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.58
Rate for Payer: Health Smart Auto/Commercial	$45.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.43
Rate for Payer: LLUH Dept of Risk Management WC	$41.65
Rate for Payer: Multiplan Commercial	$56.79

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 38779-30608
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 5155207027
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 5155207027
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

Know your out-of-pocket cost for care.

All Charges