Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$76.32

Service Code	NDC 0143-9830-01
Hospital Charge Code	1755718
Hospital Revenue Code	636
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$61.06
Rate for Payer: Cash Price	$34.34
Rate for Payer: Cigna of CA HMO/PPO	$61.06
Rate for Payer: Health Smart Auto/Commercial	$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	$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

METHOXSALEN 20 MCG/ML INJECTION SOLUTION [24933]

Facility

$69.74

Service Code	NDC 64067-216-01
Hospital Charge Code	NDG24933
Hospital Revenue Code	250
Min. Negotiated Rate	$38.36
Max. Negotiated Rate	$55.79
Rate for Payer: Cash Price	$31.38
Rate for Payer: Cigna of CA HMO/PPO	$55.79
Rate for Payer: Health Smart Auto/Commercial	$41.84
Rate for Payer: LLUH Dept of Risk Management WC	$38.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.30

METHOXSALEN 20 MCG/ML INJECTION SOLUTION [24933]

Facility

$69.74

Service Code	NDC 64067-216-01
Hospital Charge Code	NDG24933
Hospital Revenue Code	250
Min. Negotiated Rate	$38.36
Max. Negotiated Rate	$52.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.84
Rate for Payer: Aetna of CA Government/Medicare	$41.84
Rate for Payer: Cash Price	$31.38
Rate for Payer: Health Smart Auto/Commercial	$41.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.84
Rate for Payer: LLUH Dept of Risk Management WC	$38.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.30

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 38779-30608
Hospital Charge Code	NDG82259
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 5155207027
Hospital Charge Code	NDG82259
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: 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 Beech St/Commercial/PHCS	$0.03

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 5155207027
Hospital Charge Code	NDG82259
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

METHYLCELLULOSE (BULK) 1 % GEL [82599]

Facility

$0.04

Service Code	NDC 38779-30608
Hospital Charge Code	NDG82259
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: 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 Beech St/Commercial/PHCS	$0.03

METHYLDOPA 250 MG TABLET [4982]

Facility

$0.22

Service Code	NDC 51079-200-01
Hospital Charge Code	1710140
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

METHYLDOPA 250 MG TABLET [4982]

Facility

$0.22

Service Code	NDC 51079-200-01
Hospital Charge Code	1710140
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

METHYLDOPA 500 MG TABLET [4983]

Facility

$0.25

Service Code	NDC 16729-031-01
Hospital Charge Code	1710158
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

METHYLDOPA 500 MG TABLET [4983]

Facility

$0.25

Service Code	NDC 16729-031-01
Hospital Charge Code	1710158
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

METHYLDOPA ORAL SUSPENSION COMPOUND 50 MG/ML [4080300]

Facility

$1.54

Service Code	NDC 9994-0803-00
Hospital Charge Code	1715539
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.23
Rate for Payer: Cash Price	$0.69
Rate for Payer: Cigna of CA HMO/PPO	$1.23
Rate for Payer: Health Smart Auto/Commercial	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.16

METHYLDOPA ORAL SUSPENSION COMPOUND 50 MG/ML [4080300]

Facility

$1.54

Service Code	NDC 9994-0803-00
Hospital Charge Code	1715539
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.92
Rate for Payer: Aetna of CA Government/Medicare	$0.92
Rate for Payer: Cash Price	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.16

METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION [4985]

Facility

$25.20

Service Code	CPT Q9968
Hospital Charge Code	1720296
Hospital Revenue Code	636
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.12
Rate for Payer: Aetna of CA Government/Medicare	$15.12
Rate for Payer: Cash Price	$11.34
Rate for Payer: Health Smart Auto/Commercial	$15.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.12
Rate for Payer: LLUH Dept of Risk Management WC	$13.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.90

METHYLENE BLUE (ANTIDOTE) 1 % (10 MG/ML) INTRAVENOUS SOLUTION [4985]

Facility

$25.20

Service Code	CPT Q9968
Hospital Charge Code	1720296
Hospital Revenue Code	636
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$20.16
Rate for Payer: Cash Price	$11.34
Rate for Payer: Cigna of CA HMO/PPO	$20.16
Rate for Payer: Health Smart Auto/Commercial	$15.12
Rate for Payer: LLUH Dept of Risk Management WC	$13.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.90

METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [215473]

Facility

$31.25

Service Code	CPT Q9968
Hospital Charge Code	NDG215473
Hospital Revenue Code	636
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$23.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.88
Rate for Payer: Aetna of CA Government/Medicare	$16.88
Rate for Payer: Aetna of CA Government/Medicare	$18.75
Rate for Payer: Cash Price	$14.06
Rate for Payer: Cash Price	$12.66
Rate for Payer: Health Smart Auto/Commercial	$16.88
Rate for Payer: Health Smart Auto/Commercial	$18.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.75
Rate for Payer: LLUH Dept of Risk Management WC	$17.19
Rate for Payer: LLUH Dept of Risk Management WC	$15.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.44

METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [215473]

Facility

$31.25

Service Code	CPT Q9968
Hospital Charge Code	NDG215473
Hospital Revenue Code	636
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$25.00
Rate for Payer: Cigna of CA HMO/PPO	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$25.00
Rate for Payer: Health Smart Auto/Commercial	$18.75
Rate for Payer: Health Smart Auto/Commercial	$16.88
Rate for Payer: Cash Price	$14.06
Rate for Payer: Cash Price	$12.66
Rate for Payer: LLUH Dept of Risk Management WC	$17.19
Rate for Payer: LLUH Dept of Risk Management WC	$15.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.44

METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]

Facility

$23.71

Service Code	CPT J2210
Hospital Charge Code	1720284
Hospital Revenue Code	636
Min. Negotiated Rate	$13.04
Max. Negotiated Rate	$18.97
Rate for Payer: Cash Price	$10.67
Rate for Payer: Cash Price	$15.84
Rate for Payer: Cigna of CA HMO/PPO	$28.16
Rate for Payer: Cigna of CA HMO/PPO	$18.97
Rate for Payer: Health Smart Auto/Commercial	$14.23
Rate for Payer: Health Smart Auto/Commercial	$21.12
Rate for Payer: LLUH Dept of Risk Management WC	$13.04
Rate for Payer: LLUH Dept of Risk Management WC	$19.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.40

METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]

Facility

$35.20

Service Code	CPT J2210
Hospital Charge Code	1720284
Hospital Revenue Code	636
Min. Negotiated Rate	$19.36
Max. Negotiated Rate	$26.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.23
Rate for Payer: Aetna of CA Government/Medicare	$14.23
Rate for Payer: Aetna of CA Government/Medicare	$21.12
Rate for Payer: Cash Price	$15.84
Rate for Payer: Cash Price	$10.67
Rate for Payer: Health Smart Auto/Commercial	$14.23
Rate for Payer: Health Smart Auto/Commercial	$21.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.12
Rate for Payer: LLUH Dept of Risk Management WC	$19.36
Rate for Payer: LLUH Dept of Risk Management WC	$13.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.40

METHYLERGONOVINE 0.2 MG TABLET [10572]

Facility

$19.80

Service Code	NDC 69238-1605-8
Hospital Charge Code	1710513
Hospital Revenue Code	259
Min. Negotiated Rate	$10.89
Max. Negotiated Rate	$15.84
Rate for Payer: Cash Price	$8.91
Rate for Payer: Cigna of CA HMO/PPO	$15.84
Rate for Payer: Health Smart Auto/Commercial	$11.88
Rate for Payer: LLUH Dept of Risk Management WC	$10.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.85

METHYLERGONOVINE 0.2 MG TABLET [10572]

Facility

$23.83

Service Code	NDC 0093-3655-28
Hospital Charge Code	1710513
Hospital Revenue Code	259
Min. Negotiated Rate	$13.11
Max. Negotiated Rate	$17.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.30
Rate for Payer: Aetna of CA Government/Medicare	$14.30
Rate for Payer: Cash Price	$10.72
Rate for Payer: Health Smart Auto/Commercial	$14.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.30
Rate for Payer: LLUH Dept of Risk Management WC	$13.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.87

METHYLERGONOVINE 0.2 MG TABLET [10572]

Facility

$74.66

Service Code	NDC 27437-050-56
Hospital Charge Code	1710513
Hospital Revenue Code	259
Min. Negotiated Rate	$41.06
Max. Negotiated Rate	$59.73
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of CA HMO/PPO	$59.73
Rate for Payer: Health Smart Auto/Commercial	$44.80
Rate for Payer: LLUH Dept of Risk Management WC	$41.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.00

METHYLERGONOVINE 0.2 MG TABLET [10572]

Facility

$19.80

Service Code	NDC 69238-1605-8
Hospital Charge Code	1710513
Hospital Revenue Code	259
Min. Negotiated Rate	$10.89
Max. Negotiated Rate	$14.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.88
Rate for Payer: Aetna of CA Government/Medicare	$11.88
Rate for Payer: Cash Price	$8.91
Rate for Payer: Health Smart Auto/Commercial	$11.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.88
Rate for Payer: LLUH Dept of Risk Management WC	$10.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.85

METHYLERGONOVINE 0.2 MG TABLET [10572]

Facility

$74.66

Service Code	NDC 27437-050-56
Hospital Charge Code	1710513
Hospital Revenue Code	259
Min. Negotiated Rate	$41.06
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.80
Rate for Payer: Aetna of CA Government/Medicare	$44.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Health Smart Auto/Commercial	$44.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.80
Rate for Payer: LLUH Dept of Risk Management WC	$41.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.00

Know your out-of-pocket cost for care.

All Charges