Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$108.00

Service Code	NDC 39822-3030-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.80
Rate for Payer: Aetna of CA Government/Medicare	$64.80
Rate for Payer: Cash Price	$59.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: Multiplan Commercial	$81.00

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$173.40

Service Code	NDC 13925-522-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$95.37
Max. Negotiated Rate	$138.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$104.04
Rate for Payer: Aetna of CA Government/Medicare	$104.04
Rate for Payer: Cash Price	$95.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$138.72
Rate for Payer: Health Smart Auto/Commercial	$104.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$104.04
Rate for Payer: LLUH Dept of Risk Management WC	$95.37
Rate for Payer: Multiplan Commercial	$130.05

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$108.00

Service Code	NDC 39822-3030-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$86.40
Rate for Payer: Cash Price	$59.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: Multiplan Commercial	$81.00

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$108.00

Service Code	NDC 39822-3030-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.80
Rate for Payer: Aetna of CA Government/Medicare	$64.80
Rate for Payer: Cash Price	$59.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: Multiplan Commercial	$81.00

PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]

Facility

$173.40

Service Code	NDC 13925-522-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$95.37
Max. Negotiated Rate	$138.72
Rate for Payer: Cash Price	$95.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$138.72
Rate for Payer: Health Smart Auto/Commercial	$104.04
Rate for Payer: LLUH Dept of Risk Management WC	$95.37
Rate for Payer: Multiplan Commercial	$130.05

PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]

Facility

$108.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$86.40
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cash Price	$95.37
Rate for Payer: Cash Price	$64.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$138.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$93.79
Rate for Payer: Health Smart Auto/Commercial	$104.04
Rate for Payer: Health Smart Auto/Commercial	$70.34
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$95.37
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$64.48
Rate for Payer: Multiplan Commercial	$130.05
Rate for Payer: Multiplan Commercial	$87.93
Rate for Payer: Multiplan Commercial	$81.00

PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]

Facility

$173.40

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$95.37
Max. Negotiated Rate	$138.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$104.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.34
Rate for Payer: Aetna of CA Government/Medicare	$64.80
Rate for Payer: Aetna of CA Government/Medicare	$70.34
Rate for Payer: Aetna of CA Government/Medicare	$104.04
Rate for Payer: Cash Price	$64.48
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cash Price	$95.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$138.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$93.79
Rate for Payer: Health Smart Auto/Commercial	$104.04
Rate for Payer: Health Smart Auto/Commercial	$70.34
Rate for Payer: Health Smart Auto/Commercial	$64.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$104.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.80
Rate for Payer: LLUH Dept of Risk Management WC	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$64.48
Rate for Payer: LLUH Dept of Risk Management WC	$95.37
Rate for Payer: Multiplan Commercial	$87.93
Rate for Payer: Multiplan Commercial	$81.00
Rate for Payer: Multiplan Commercial	$130.05

PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]

Facility

$72.60

Service Code	HCPCS J2515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$39.93
Max. Negotiated Rate	$58.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.50
Rate for Payer: Aetna of CA Government/Medicare	$30.24
Rate for Payer: Aetna of CA Government/Medicare	$43.56
Rate for Payer: Aetna of CA Government/Medicare	$32.50
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$39.93
Rate for Payer: Cash Price	$29.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$58.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.34
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: Health Smart Auto/Commercial	$32.50
Rate for Payer: Health Smart Auto/Commercial	$43.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.56
Rate for Payer: LLUH Dept of Risk Management WC	$29.79
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$39.93
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$40.63
Rate for Payer: Multiplan Commercial	$54.45

PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]

Facility

$72.60

Service Code	HCPCS J2515
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$39.93
Max. Negotiated Rate	$58.08
Rate for Payer: Cash Price	$39.93
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$29.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$58.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: Health Smart Auto/Commercial	$32.50
Rate for Payer: Health Smart Auto/Commercial	$43.56
Rate for Payer: LLUH Dept of Risk Management WC	$39.93
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$29.79
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$40.63
Rate for Payer: Multiplan Commercial	$54.45

PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]

Facility

$14.37

Service Code	NDC 50458-098-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.62
Rate for Payer: Aetna of CA Government/Medicare	$8.62
Rate for Payer: Cash Price	$7.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.50
Rate for Payer: Health Smart Auto/Commercial	$8.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.62
Rate for Payer: LLUH Dept of Risk Management WC	$7.90
Rate for Payer: Multiplan Commercial	$10.78

PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]

Facility

$14.37

Service Code	NDC 50458-098-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$11.50
Rate for Payer: Cash Price	$7.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.50
Rate for Payer: Health Smart Auto/Commercial	$8.62
Rate for Payer: LLUH Dept of Risk Management WC	$7.90
Rate for Payer: Multiplan Commercial	$10.78

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.51

Service Code	NDC 60505-0033-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.37

Service Code	NDC 0904-5448-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
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	$0.28

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.37

Service Code	NDC 0904-5448-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
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	$0.30
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	$0.28

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.51

Service Code	NDC 60505-0033-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]

Facility

$0.03

Service Code	NDC 9994-0803-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
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	$0.02

PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]

Facility

$0.03

Service Code	NDC 9994-0803-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.02
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	$0.02

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.34

Service Code	NDC 0395224391
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.34

Service Code	NDC 0395224391
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.90

Service Code	NDC 0395201591
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.49
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

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.90

Service Code	NDC 0395201591
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	$0.49
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

PERAMPANEL 2 MG TABLET [204501]

Facility

$24.84

Service Code	NDC 62856-272-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.66
Max. Negotiated Rate	$19.87
Rate for Payer: Cash Price	$13.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.87
Rate for Payer: Health Smart Auto/Commercial	$14.90
Rate for Payer: LLUH Dept of Risk Management WC	$13.66
Rate for Payer: Multiplan Commercial	$18.63

PERAMPANEL 2 MG TABLET [204501]

Facility

$24.84

Service Code	NDC 62856-272-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.66
Max. Negotiated Rate	$19.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.90
Rate for Payer: Aetna of CA Government/Medicare	$14.90
Rate for Payer: Cash Price	$13.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.87
Rate for Payer: Health Smart Auto/Commercial	$14.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.90
Rate for Payer: LLUH Dept of Risk Management WC	$13.66
Rate for Payer: Multiplan Commercial	$18.63

PERAMPANEL 2 MG TABLET [204501]

Facility

$24.84

Service Code	NDC 69616-272-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.66
Max. Negotiated Rate	$19.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.90
Rate for Payer: Aetna of CA Government/Medicare	$14.90
Rate for Payer: Cash Price	$13.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.87
Rate for Payer: Health Smart Auto/Commercial	$14.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.90
Rate for Payer: LLUH Dept of Risk Management WC	$13.66
Rate for Payer: Multiplan Commercial	$18.63

PERAMPANEL 2 MG TABLET [204501]

Facility

$24.84

Service Code	NDC 69616-272-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.66
Max. Negotiated Rate	$19.87
Rate for Payer: Cash Price	$13.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.87
Rate for Payer: Health Smart Auto/Commercial	$14.90
Rate for Payer: LLUH Dept of Risk Management WC	$13.66
Rate for Payer: Multiplan Commercial	$18.63

Know your out-of-pocket cost for care.

All Charges