Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.40

Service Code	NDC 50268-521-15
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.37

Service Code	NDC 60687-568-11
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.28

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.37

Service Code	NDC 60687-568-01
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
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	$0.17
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 Beech St/Commercial/PHCS	$0.28

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.17

Service Code	NDC 31722-534-01
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.11

Service Code	NDC 76385-124-01
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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	$0.05
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	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.37

Service Code	NDC 60687-568-01
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.28

METHOCARBAMOL 750 MG TABLET [4972]

Facility

$0.08

Service Code	NDC 70010-770-01
Hospital Charge Code	1710657
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

METHOHEXITAL 500 MG SOLUTION FOR INJECTION [70545]

Facility

$110.83

Service Code	CPT J3490
Hospital Charge Code	1737031
Hospital Revenue Code	636
Min. Negotiated Rate	$60.96
Max. Negotiated Rate	$88.66
Rate for Payer: Cash Price	$49.87
Rate for Payer: Cigna of CA HMO/PPO	$88.66
Rate for Payer: Health Smart Auto/Commercial	$66.50
Rate for Payer: LLUH Dept of Risk Management WC	$60.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$83.12

METHOHEXITAL 500 MG SOLUTION FOR INJECTION [70545]

Facility

$110.83

Service Code	CPT J3490
Hospital Charge Code	1737031
Hospital Revenue Code	636
Min. Negotiated Rate	$60.96
Max. Negotiated Rate	$83.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.50
Rate for Payer: Aetna of CA Government/Medicare	$66.50
Rate for Payer: Cash Price	$49.87
Rate for Payer: Health Smart Auto/Commercial	$66.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.50
Rate for Payer: LLUH Dept of Risk Management WC	$60.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$83.12

METHOTREXATE ORAL SUSP IV FORM COMPOUND 2 MG/ML [4080299]

Facility

$0.81

Service Code	NDC 9994-0802-99
Hospital Charge Code	1715136
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

METHOTREXATE ORAL SUSP IV FORM COMPOUND 2 MG/ML [4080299]

Facility

$0.81

Service Code	NDC 9994-0802-99
Hospital Charge Code	1715136
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

METHOTREXATE SODIUM 1.25 MG 1/2 TABLET [4081484]

Facility

$2.83

Service Code	CPT J8610
Hospital Charge Code	ERX4081484
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.70
Rate for Payer: Aetna of CA Government/Medicare	$1.70
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.12

METHOTREXATE SODIUM 1.25 MG 1/2 TABLET [4081484]

Facility

$2.83

Service Code	CPT J8610
Hospital Charge Code	ERX4081484
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.27
Rate for Payer: Cigna of CA HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.12

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]

Facility

$4.03

Service Code	CPT J9250
Hospital Charge Code	NDG4974B
Hospital Revenue Code	636
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.42
Rate for Payer: Aetna of CA Government/Medicare	$2.42
Rate for Payer: Cash Price	$1.81
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.02

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]

Facility

$4.36

Service Code	CPT J9250
Hospital Charge Code	NDG4974A
Hospital Revenue Code	636
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.62
Rate for Payer: Aetna of CA Government/Medicare	$2.62
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.27

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]

Facility

$4.03

Service Code	CPT J9250
Hospital Charge Code	NDG4974B
Hospital Revenue Code	636
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.22
Rate for Payer: Cash Price	$1.81
Rate for Payer: Cigna of CA HMO/PPO	$3.22
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.02

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [4974]

Facility

$4.36

Service Code	CPT J9250
Hospital Charge Code	NDG4974A
Hospital Revenue Code	636
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.49
Rate for Payer: Cash Price	$1.96
Rate for Payer: Cigna of CA HMO/PPO	$3.49
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.27

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION WRAP. (FOR CNR ONLY) [4081565]

Facility

$1.12

Service Code	CPT J9260
Hospital Charge Code	NDG96981B
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Cash Price	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.84

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION WRAP. (FOR CNR ONLY) [4081565]

Facility

$1.12

Service Code	CPT J9260
Hospital Charge Code	NDG96981B
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cigna of CA HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.84

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION WRAP. (FOR CNR ONLY) [4081565]

Facility

$1.00

Service Code	CPT J9260
Hospital Charge Code	NDG1739
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION WRAP. (FOR CNR ONLY) [4081565]

Facility

$1.00

Service Code	CPT J9260
Hospital Charge Code	NDG1739
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

METHOTREXATE SODIUM 2.5 MG TABLET [4973]

Facility

$3.32

Service Code	CPT J8610
Hospital Charge Code	1710517
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.49
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

METHOTREXATE SODIUM 2.5 MG TABLET [4973]

Facility

$0.66

Service Code	CPT J8610
Hospital Charge Code	1710517
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.99
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$1.99
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$1.49
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION [4975]

Facility

$76.32

Service Code	NDC 63323-122-50
Hospital Charge Code	1755718
Hospital Revenue Code	636
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$57.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.79
Rate for Payer: Aetna of CA Government/Medicare	$45.79
Rate for Payer: Cash Price	$34.34
Rate for Payer: Health Smart Auto/Commercial	$45.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.79
Rate for Payer: LLUH Dept of Risk Management WC	$41.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$57.24

METHOTREXATE SODIUM (PF) 1 GRAM SOLUTION FOR INJECTION [4975]

Facility

$76.32

Service Code	NDC 63323-122-50
Hospital Charge Code	1755718
Hospital Revenue Code	636
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$61.06
Rate for Payer: Cigna of CA HMO/PPO	$61.06
Rate for Payer: Health Smart Auto/Commercial	$45.79
Rate for Payer: Cash Price	$34.34
Rate for Payer: LLUH Dept of Risk Management WC	$41.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$57.24

Know your out-of-pocket cost for care.

All Charges