Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

$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: 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 5 MG TABLET [10588]

Facility

$0.81

Service Code	NDC 0185-0055-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.45
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

METOLAZONE 5 MG TABLET [10588]

Facility

$0.36

Service Code	NDC 72888-053-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

METOLAZONE 5 MG TABLET [10588]

Facility

$0.90

Service Code	NDC 76385-137-01
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

METOLAZONE 5 MG TABLET [10588]

Facility

$2.46

Service Code	NDC 0378-6173-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.97
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.97
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

METOLAZONE 5 MG TABLET [10588]

Facility

$0.36

Service Code	NDC 72888-053-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

METOLAZONE 5 MG TABLET [10588]

Facility

$4.11

Service Code	NDC 60687-635-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$3.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.47
Rate for Payer: Cash Price	$2.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.29
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.26
Rate for Payer: Multiplan Commercial	$3.08

METOLAZONE 5 MG TABLET [10588]

Facility

$3.73

Service Code	NDC 51079-024-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.80

METOLAZONE 5 MG TABLET [10588]

Facility

$3.73

Service Code	NDC 51079-024-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
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	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
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	$2.05
Rate for Payer: Multiplan Commercial	$2.80

METOLAZONE 5 MG TABLET [10588]

Facility

$0.90

Service Code	NDC 76385-137-01
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

METOLAZONE 5 MG TABLET [10588]

Facility

$4.11

Service Code	NDC 60687-635-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$3.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.47
Rate for Payer: Cash Price	$2.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.29
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.26
Rate for Payer: Multiplan Commercial	$3.08

METOLAZONE 5 MG TABLET [10588]

Facility

$0.81

Service Code	NDC 0185-0055-01
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	$0.45
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

METOLAZONE 5 MG TABLET [10588]

Facility

$3.73

Service Code	NDC 51079-024-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
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	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
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	$2.05
Rate for Payer: Multiplan Commercial	$2.80

METOLAZONE 5 MG TABLET [10588]

Facility

$2.46

Service Code	NDC 0378-6173-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.97
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

METOLAZONE 5 MG TABLET [10588]

Facility

$4.11

Service Code	NDC 60687-635-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$3.29
Rate for Payer: Cash Price	$2.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.29
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.26
Rate for Payer: Multiplan Commercial	$3.08

METOLAZONE 5 MG TABLET [10588]

Facility

$3.73

Service Code	NDC 51079-024-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.80

METOLAZONE 5 MG TABLET [10588]

Facility

$4.11

Service Code	NDC 60687-635-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$3.29
Rate for Payer: Cash Price	$2.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.29
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.26
Rate for Payer: Multiplan Commercial	$3.08

METOLAZONE ORAL SUSPENSION COMPOUND 1 MG/ML [4080301]

Facility

$0.18

Service Code	NDC 9994-0803-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

METOLAZONE ORAL SUSPENSION COMPOUND 1 MG/ML [4080301]

Facility

$0.18

Service Code	NDC 9994-0803-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [30071]

Facility

$1.68

Service Code	NDC 60687-413-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [30071]

Facility

$0.89

Service Code	NDC 68001-502-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.49
Rate for Payer: Multiplan Commercial	$0.67

METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [30071]

Facility

$0.11

Service Code	NDC 72516-032-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [30071]

Facility

$1.68

Service Code	NDC 60687-413-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR [30071]

Facility

$0.68

Service Code	NDC 50268-542-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

Know your out-of-pocket cost for care.

All Charges