Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]

Facility

$0.74

Service Code	HCPCS J2765
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$1.11
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$1.51
Rate for Payer: Multiplan Commercial	$0.99
Rate for Payer: Multiplan Commercial	$0.56

METOCLOPRAMIDE 5 MG TABLET [5006]

Facility

$0.90

Service Code	NDC 51079-886-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

METOCLOPRAMIDE 5 MG TABLET [5006]

Facility

$0.09

Service Code	NDC 0093-2204-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
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

METOCLOPRAMIDE 5 MG TABLET [5006]

Facility

$0.90

Service Code	NDC 51079-886-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

METOCLOPRAMIDE 5 MG TABLET [5006]

Facility

$0.90

Service Code	NDC 51079-886-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

METOCLOPRAMIDE 5 MG TABLET [5006]

Facility

$0.90

Service Code	NDC 51079-886-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

METOCLOPRAMIDE 5 MG TABLET [5006]

Facility

$0.09

Service Code	NDC 0093-2204-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
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

METOLAZONE 10 MG TABLET [10586]

Facility

$1.08

Service Code	NDC 0185-5600-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

METOLAZONE 10 MG TABLET [10586]

Facility

$1.08

Service Code	NDC 76385-138-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

METOLAZONE 10 MG TABLET [10586]

Facility

$1.08

Service Code	NDC 76385-138-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

METOLAZONE 10 MG TABLET [10586]

Facility

$0.78

Service Code	NDC 50742-351-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

METOLAZONE 10 MG TABLET [10586]

Facility

$1.08

Service Code	NDC 0185-5600-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

METOLAZONE 10 MG TABLET [10586]

Facility

$0.78

Service Code	NDC 50742-351-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

METOLAZONE 10 MG TABLET [10586]

Facility

$0.48

Service Code	NDC 72888-054-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
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: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

METOLAZONE 10 MG TABLET [10586]

Facility

$0.48

Service Code	NDC 72888-054-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
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: Cash Price	$0.26
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

METOLAZONE 2.5 MG TABLET [10587]

Facility

$0.78

Service Code	NDC 76385-136-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

METOLAZONE 2.5 MG TABLET [10587]

Facility

$0.70

Service Code	NDC 0185-5050-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

METOLAZONE 2.5 MG TABLET [10587]

Facility

$0.70

Service Code	NDC 0185-5050-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

METOLAZONE 2.5 MG TABLET [10587]

Facility

$3.29

Service Code	NDC 51079-023-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.97
Rate for Payer: Aetna of CA Government/Medicare	$1.97
Rate for Payer: Cash Price	$1.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.63
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Commercial	$2.47

METOLAZONE 2.5 MG TABLET [10587]

Facility

$3.29

Service Code	NDC 51079-023-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.97
Rate for Payer: Aetna of CA Government/Medicare	$1.97
Rate for Payer: Cash Price	$1.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.63
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Commercial	$2.47

METOLAZONE 2.5 MG TABLET [10587]

Facility

$0.78

Service Code	NDC 76385-136-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

METOLAZONE 2.5 MG TABLET [10587]

Facility

$0.78

Service Code	NDC 62332-532-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

METOLAZONE 2.5 MG TABLET [10587]

Facility

$2.16

Service Code	NDC 0378-6172-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.73
Rate for Payer: Cash Price	$1.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.73
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: Multiplan Commercial	$1.62

METOLAZONE 2.5 MG TABLET [10587]

Facility

$3.29

Service Code	NDC 51079-023-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.63
Rate for Payer: Cash Price	$1.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.63
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Commercial	$2.47

METOLAZONE 2.5 MG TABLET [10587]

Facility

$2.16

Service Code	NDC 0378-6172-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.30
Rate for Payer: Aetna of CA Government/Medicare	$1.30
Rate for Payer: Cash Price	$1.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.73
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.30
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: Multiplan Commercial	$1.62

Know your out-of-pocket cost for care.

All Charges