Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHENYLEPHRINE 2.5 %-TROPICAMIDE 1 % IN STERILE WATER EYE DROPS [225990]

Facility

$3.60

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$1.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$1.51
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$1.39
Rate for Payer: Multiplan Commercial	$1.89
Rate for Payer: Multiplan Commercial	$2.70

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$2.01

Service Code	NDC 60687-275-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$2.01

Service Code	NDC 60687-275-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$2.01

Service Code	NDC 60687-275-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$2.01

Service Code	NDC 60687-275-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.12

Service Code	NDC 51672-4069-2
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

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.12

Service Code	NDC 51672-4069-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.14

Service Code	NDC 9999-9379-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
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

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.14

Service Code	NDC 9999-9379-93
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	$0.08
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

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.80

Service Code	NDC 60687-156-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.35

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.89

Service Code	NDC 0071-0007-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.13
Rate for Payer: Aetna of CA Government/Medicare	$1.13
Rate for Payer: Cash Price	$1.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.51
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Commercial	$1.42

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.80

Service Code	NDC 60687-156-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.35

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.89

Service Code	NDC 0071-0007-24
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.51
Rate for Payer: Cash Price	$1.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.51
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Commercial	$1.42

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$0.50

Service Code	NDC 51672-4146-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$0.50

Service Code	NDC 51672-4146-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]

Facility

$0.83

Service Code	HCPCS J1165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.62
Rate for Payer: Multiplan Commercial	$0.90

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]

Facility

$0.83

Service Code	HCPCS J1165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$0.62

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.30

Service Code	NDC 57664-808-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.41

Service Code	NDC 65862-692-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.30

Service Code	NDC 51672-4111-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$1.87

Service Code	NDC 60687-841-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.12
Rate for Payer: Aetna of CA Government/Medicare	$1.12
Rate for Payer: Cash Price	$1.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.50
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Commercial	$1.40

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$1.87

Service Code	NDC 60687-841-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.50
Rate for Payer: Cash Price	$1.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.50
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Commercial	$1.40

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.30

Service Code	NDC 51672-4111-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.41

Service Code	NDC 65862-692-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.30

Service Code	NDC 57664-808-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

Know your out-of-pocket cost for care.

All Charges