Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

POVIDONE-IODINE 5 % EYE SOLUTION [19791]

Facility

$0.71

Service Code	NDC 0065-0411-30
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

POVIDONE-IODINE (BULK) 100 % POWDER [39708]

Facility

$1.23

Service Code	NDC 38779-2912-5
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Commercial	$0.92

POVIDONE-IODINE (BULK) 100 % POWDER [39708]

Facility

$1.23

Service Code	NDC 38779-2912-5
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Commercial	$0.92

PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]

Facility

$104.04

Service Code	HCPCS J2730
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$57.22
Max. Negotiated Rate	$83.23
Rate for Payer: Cash Price	$57.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.23
Rate for Payer: Health Smart Auto/Commercial	$62.42
Rate for Payer: LLUH Dept of Risk Management WC	$57.22
Rate for Payer: Multiplan Commercial	$78.03

PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]

Facility

$104.04

Service Code	HCPCS J2730
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$57.22
Max. Negotiated Rate	$83.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.42
Rate for Payer: Aetna of CA Government/Medicare	$62.42
Rate for Payer: Cash Price	$57.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.23
Rate for Payer: Health Smart Auto/Commercial	$62.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.42
Rate for Payer: LLUH Dept of Risk Management WC	$57.22
Rate for Payer: Multiplan Commercial	$78.03

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.13

Service Code	NDC 68462-330-90
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	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.18

Service Code	NDC 13668-091-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.13

Service Code	NDC 68462-330-90
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.18

Service Code	NDC 13668-091-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 0.25 MG TABLET [21290]

Facility

$0.18

Service Code	NDC 13668-092-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 0.25 MG TABLET [21290]

Facility

$0.18

Service Code	NDC 13668-092-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
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	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
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 Commercial	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$0.18

Service Code	NDC 13668-093-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
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	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
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 Commercial	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$0.18

Service Code	NDC 13668-093-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.18

Service Code	NDC 13668-094-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.13

Service Code	NDC 68462-333-90
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.13

Service Code	NDC 68462-333-90
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	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.18

Service Code	NDC 13668-094-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

PRASUGREL HCL 10 MG TABLET [98373]

Facility

$0.99

Service Code	NDC 16729-273-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

PRASUGREL HCL 10 MG TABLET [98373]

Facility

$0.23

Service Code	NDC 51407-445-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

PRASUGREL HCL 10 MG TABLET [98373]

Facility

$0.99

Service Code	NDC 65862-830-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

PRASUGREL HCL 10 MG TABLET [98373]

Facility

$0.99

Service Code	NDC 16729-273-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

Know your out-of-pocket cost for care.

All Charges