Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]

Facility

$3.45

Service Code	NDC 50268-624-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$2.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.07
Rate for Payer: Aetna of CA Government/Medicare	$2.07
Rate for Payer: Cash Price	$1.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.76
Rate for Payer: Health Smart Auto/Commercial	$2.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.07
Rate for Payer: LLUH Dept of Risk Management WC	$1.90
Rate for Payer: Multiplan Commercial	$2.59

NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]

Facility

$3.45

Service Code	NDC 50268-624-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$2.76
Rate for Payer: Cash Price	$1.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.76
Rate for Payer: Health Smart Auto/Commercial	$2.07
Rate for Payer: LLUH Dept of Risk Management WC	$1.90
Rate for Payer: Multiplan Commercial	$2.59

NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE [5593]

Facility

$3.45

Service Code	NDC 50268-624-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$2.76
Rate for Payer: Cash Price	$1.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.76
Rate for Payer: Health Smart Auto/Commercial	$2.07
Rate for Payer: LLUH Dept of Risk Management WC	$1.90
Rate for Payer: Multiplan Commercial	$2.59

NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE [5595]

Facility

$0.25

Service Code	NDC 62332-390-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE [5595]

Facility

$0.25

Service Code	NDC 62332-390-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]

Facility

$0.43

Service Code	NDC 70756-404-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]

Facility

$0.60

Service Code	NDC 0185-0122-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]

Facility

$0.43

Service Code	NDC 70756-404-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE [10724]

Facility

$0.60

Service Code	NDC 0185-0122-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH [27471]

Facility

$0.73

Service Code	NDC 0378-9102-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH [27471]

Facility

$0.73

Service Code	NDC 0378-9102-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH [27471]

Facility

$0.73

Service Code	NDC 0378-9102-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH [27471]

Facility

$0.73

Service Code	NDC 0378-9102-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH [27472]

Facility

$0.85

Service Code	NDC 49730-111-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.68
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.64

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH [27472]

Facility

$0.85

Service Code	NDC 0378-9104-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.51
Rate for Payer: Aetna of CA Government/Medicare	$0.51
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.64

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH [27472]

Facility

$0.85

Service Code	NDC 49730-111-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.51
Rate for Payer: Aetna of CA Government/Medicare	$0.51
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.64

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH [27472]

Facility

$0.85

Service Code	NDC 0378-9104-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.68
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.64

NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH [27474]

Facility

$0.98

Service Code	NDC 0378-9112-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH [27474]

Facility

$0.98

Service Code	NDC 0378-9112-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH [27474]

Facility

$0.98

Service Code	NDC 0378-9112-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH [27474]

Facility

$0.98

Service Code	NDC 0378-9112-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$1.02

Service Code	NDC 43598-436-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.77

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$0.12

Service Code	NDC 68462-639-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$1.02

Service Code	NDC 43598-436-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
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	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
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 Commercial	$0.77

NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]

Facility

$1.02

Service Code	NDC 43598-436-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
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	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
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 Commercial	$0.77

Know your out-of-pocket cost for care.

All Charges