Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$1.87

Service Code	NDC 60687-841-11
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 60687-841-11
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 30 MG CAPSULE [11019]

Facility

$1.79

Service Code	NDC 0071-3740-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.43
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Commercial	$1.34

PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]

Facility

$1.79

Service Code	NDC 0071-3740-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.43
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Commercial	$1.34

PHOS-NAK ORAL SOLN CMPND 25 MG/ML (0.8 MMOL/ML) [4080310]

Facility

$0.04

Service Code	NDC 9994-0803-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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	$0.03

PHOS-NAK ORAL SOLN CMPND 25 MG/ML (0.8 MMOL/ML) [4080310]

Facility

$0.04

Service Code	NDC 9994-0803-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.03
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	$0.03

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-06
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-05
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-05
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-06
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]

Facility

$0.01

Service Code	NDC 24571-117-05
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]

Facility

$0.01

Service Code	NDC 24571-117-05
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]

Facility

$51.32

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$28.23
Max. Negotiated Rate	$41.06
Rate for Payer: Cash Price	$28.23
Rate for Payer: Cash Price	$32.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$41.06
Rate for Payer: Health Smart Auto/Commercial	$30.79
Rate for Payer: Health Smart Auto/Commercial	$35.26
Rate for Payer: LLUH Dept of Risk Management WC	$28.23
Rate for Payer: LLUH Dept of Risk Management WC	$32.32
Rate for Payer: Multiplan Commercial	$38.49
Rate for Payer: Multiplan Commercial	$44.07

PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]

Facility

$58.76

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.32
Max. Negotiated Rate	$47.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.79
Rate for Payer: Aetna of CA Government/Medicare	$35.26
Rate for Payer: Aetna of CA Government/Medicare	$30.79
Rate for Payer: Cash Price	$32.32
Rate for Payer: Cash Price	$28.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$41.06
Rate for Payer: Health Smart Auto/Commercial	$30.79
Rate for Payer: Health Smart Auto/Commercial	$35.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.79
Rate for Payer: LLUH Dept of Risk Management WC	$28.23
Rate for Payer: LLUH Dept of Risk Management WC	$32.32
Rate for Payer: Multiplan Commercial	$44.07
Rate for Payer: Multiplan Commercial	$38.49

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]

Facility

$11.39

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$9.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.83
Rate for Payer: Aetna of CA Government/Medicare	$6.83
Rate for Payer: Cash Price	$6.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.11
Rate for Payer: Health Smart Auto/Commercial	$6.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.83
Rate for Payer: LLUH Dept of Risk Management WC	$6.26
Rate for Payer: Multiplan Commercial	$8.54

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]

Facility

$11.39

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$9.11
Rate for Payer: Cash Price	$6.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.11
Rate for Payer: Health Smart Auto/Commercial	$6.83
Rate for Payer: LLUH Dept of Risk Management WC	$6.26
Rate for Payer: Multiplan Commercial	$8.54

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]

Facility

$59.35

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$47.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.61
Rate for Payer: Aetna of CA Government/Medicare	$35.61
Rate for Payer: Cash Price	$32.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.48
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Commercial	$44.51

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]

Facility

$59.35

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$47.48
Rate for Payer: Cash Price	$32.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.48
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Commercial	$44.51

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]

Facility

$59.35

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$47.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.61
Rate for Payer: Aetna of CA Government/Medicare	$35.61
Rate for Payer: Cash Price	$32.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.48
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Commercial	$44.51

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]

Facility

$59.35

Service Code	HCPCS J3430
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$47.48
Rate for Payer: Cash Price	$32.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.48
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Commercial	$44.51

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$80.85

Service Code	NDC 60687-381-94
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$44.47
Max. Negotiated Rate	$64.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.51
Rate for Payer: Aetna of CA Government/Medicare	$48.51
Rate for Payer: Cash Price	$44.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.68
Rate for Payer: Health Smart Auto/Commercial	$48.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.51
Rate for Payer: LLUH Dept of Risk Management WC	$44.47
Rate for Payer: Multiplan Commercial	$60.64

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$80.85

Service Code	NDC 60687-381-94
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$44.47
Max. Negotiated Rate	$64.68
Rate for Payer: Cash Price	$44.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.68
Rate for Payer: Health Smart Auto/Commercial	$48.51
Rate for Payer: LLUH Dept of Risk Management WC	$44.47
Rate for Payer: Multiplan Commercial	$60.64

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$33.76

Service Code	NDC 70710-1014-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.57
Max. Negotiated Rate	$27.01
Rate for Payer: Cash Price	$18.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.01
Rate for Payer: Health Smart Auto/Commercial	$20.26
Rate for Payer: LLUH Dept of Risk Management WC	$18.57
Rate for Payer: Multiplan Commercial	$25.32

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$27.01

Service Code	NDC 69097-999-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$14.86
Max. Negotiated Rate	$21.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.21
Rate for Payer: Aetna of CA Government/Medicare	$16.21
Rate for Payer: Cash Price	$14.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.61
Rate for Payer: Health Smart Auto/Commercial	$16.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.21
Rate for Payer: LLUH Dept of Risk Management WC	$14.86
Rate for Payer: Multiplan Commercial	$20.26

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$27.01

Service Code	NDC 69097-999-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$14.86
Max. Negotiated Rate	$21.61
Rate for Payer: Cash Price	$14.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.61
Rate for Payer: Health Smart Auto/Commercial	$16.21
Rate for Payer: LLUH Dept of Risk Management WC	$14.86
Rate for Payer: Multiplan Commercial	$20.26

Know your out-of-pocket cost for care.

All Charges