Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]

Facility

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]

Facility

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]

Facility

$0.14

Service Code	NDC 57896-184-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]

Facility

$1.22

Service Code	NDC 0065-1431-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]

Facility

$0.62

Service Code	NDC 0065-0429-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]

Facility

$1.22

Service Code	NDC 0065-1431-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]

Facility

$1.16

Service Code	NDC 0065-1431-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]

Facility

$1.16

Service Code	NDC 0065-1431-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]

Facility

$0.62

Service Code	NDC 0065-0429-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]

Facility

$291.54

Service Code	HCPCS J2781
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$160.35
Max. Negotiated Rate	$233.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$174.92
Rate for Payer: Aetna of CA Government/Medicare	$174.92
Rate for Payer: Cash Price	$160.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$233.23
Rate for Payer: Health Smart Auto/Commercial	$174.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$174.92
Rate for Payer: LLUH Dept of Risk Management WC	$160.35
Rate for Payer: Multiplan Commercial	$218.66

PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]

Facility

$291.54

Service Code	HCPCS J2781
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$160.35
Max. Negotiated Rate	$233.23
Rate for Payer: Cash Price	$160.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$233.23
Rate for Payer: Health Smart Auto/Commercial	$174.92
Rate for Payer: LLUH Dept of Risk Management WC	$160.35
Rate for Payer: Multiplan Commercial	$218.66

PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]

Facility

$190.80

Service Code	HCPCS J9305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$104.94
Max. Negotiated Rate	$152.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$114.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$114.48
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$104.94
Rate for Payer: Cash Price	$82.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$152.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Health Smart Auto/Commercial	$114.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$114.48
Rate for Payer: LLUH Dept of Risk Management WC	$104.94
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$143.10
Rate for Payer: Multiplan Commercial	$112.50

PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]

Facility

$190.80

Service Code	HCPCS J9305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$104.94
Max. Negotiated Rate	$152.64
Rate for Payer: Cash Price	$104.94
Rate for Payer: Cash Price	$82.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$152.64
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Health Smart Auto/Commercial	$114.48
Rate for Payer: LLUH Dept of Risk Management WC	$104.94
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50
Rate for Payer: Multiplan Commercial	$143.10

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$600.00

Service Code	HCPCS J9305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$480.00
Rate for Payer: Cash Price	$330.00
Rate for Payer: Cash Price	$523.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$761.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$480.00
Rate for Payer: Health Smart Auto/Commercial	$360.00
Rate for Payer: Health Smart Auto/Commercial	$570.96
Rate for Payer: LLUH Dept of Risk Management WC	$330.00
Rate for Payer: LLUH Dept of Risk Management WC	$523.38
Rate for Payer: Multiplan Commercial	$713.70
Rate for Payer: Multiplan Commercial	$450.00

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$600.00

Service Code	HCPCS J9305
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$480.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$360.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$570.96
Rate for Payer: Aetna of CA Government/Medicare	$360.00
Rate for Payer: Aetna of CA Government/Medicare	$570.96
Rate for Payer: Cash Price	$330.00
Rate for Payer: Cash Price	$523.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$480.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$761.28
Rate for Payer: Health Smart Auto/Commercial	$360.00
Rate for Payer: Health Smart Auto/Commercial	$570.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$360.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$570.96
Rate for Payer: LLUH Dept of Risk Management WC	$523.38
Rate for Payer: LLUH Dept of Risk Management WC	$330.00
Rate for Payer: Multiplan Commercial	$450.00
Rate for Payer: Multiplan Commercial	$713.70

PENICILLAMINE 250 MG CAPSULE [10894]

Facility

$314.26

Service Code	NDC 25010-705-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$172.84
Max. Negotiated Rate	$251.41
Rate for Payer: Cash Price	$172.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$251.41
Rate for Payer: Health Smart Auto/Commercial	$188.56
Rate for Payer: LLUH Dept of Risk Management WC	$172.84
Rate for Payer: Multiplan Commercial	$235.69

PENICILLAMINE 250 MG CAPSULE [10894]

Facility

$314.26

Service Code	NDC 25010-705-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$172.84
Max. Negotiated Rate	$251.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$188.56
Rate for Payer: Aetna of CA Government/Medicare	$188.56
Rate for Payer: Cash Price	$172.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$251.41
Rate for Payer: Health Smart Auto/Commercial	$188.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$188.56
Rate for Payer: LLUH Dept of Risk Management WC	$172.84
Rate for Payer: Multiplan Commercial	$235.69

PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]

Facility

$1.75

Service Code	NDC 9994-0803-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.05
Rate for Payer: Aetna of CA Government/Medicare	$1.05
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.31

PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]

Facility

$1.75

Service Code	NDC 9994-0803-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.40
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.31

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]

Facility

$221.42

Service Code	HCPCS J0561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$121.78
Max. Negotiated Rate	$177.14
Rate for Payer: Cash Price	$121.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.14
Rate for Payer: Health Smart Auto/Commercial	$132.85
Rate for Payer: LLUH Dept of Risk Management WC	$121.78
Rate for Payer: Multiplan Commercial	$166.06

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]

Facility

$221.42

Service Code	HCPCS J0561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$121.78
Max. Negotiated Rate	$177.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$132.85
Rate for Payer: Aetna of CA Government/Medicare	$132.85
Rate for Payer: Cash Price	$121.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.14
Rate for Payer: Health Smart Auto/Commercial	$132.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$132.85
Rate for Payer: LLUH Dept of Risk Management WC	$121.78
Rate for Payer: Multiplan Commercial	$166.06

PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]

Facility

$226.86

Service Code	HCPCS J0561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$124.77
Max. Negotiated Rate	$181.49
Rate for Payer: Cash Price	$124.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$181.49
Rate for Payer: Health Smart Auto/Commercial	$136.12
Rate for Payer: LLUH Dept of Risk Management WC	$124.77
Rate for Payer: Multiplan Commercial	$170.15

PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]

Facility

$226.86

Service Code	HCPCS J0561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$124.77
Max. Negotiated Rate	$181.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$136.12
Rate for Payer: Aetna of CA Government/Medicare	$136.12
Rate for Payer: Cash Price	$124.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$181.49
Rate for Payer: Health Smart Auto/Commercial	$136.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$136.12
Rate for Payer: LLUH Dept of Risk Management WC	$124.77
Rate for Payer: Multiplan Commercial	$170.15

PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]

Facility

$255.69

Service Code	HCPCS J0561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$140.63
Max. Negotiated Rate	$204.55
Rate for Payer: Cash Price	$140.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.55
Rate for Payer: Health Smart Auto/Commercial	$153.41
Rate for Payer: LLUH Dept of Risk Management WC	$140.63
Rate for Payer: Multiplan Commercial	$191.77

PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]

Facility

$255.69

Service Code	HCPCS J0561
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$140.63
Max. Negotiated Rate	$204.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$153.41
Rate for Payer: Aetna of CA Government/Medicare	$153.41
Rate for Payer: Cash Price	$140.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.55
Rate for Payer: Health Smart Auto/Commercial	$153.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$153.41
Rate for Payer: LLUH Dept of Risk Management WC	$140.63
Rate for Payer: Multiplan Commercial	$191.77

Know your out-of-pocket cost for care.

All Charges