Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PRIMIDONE 50 MG TABLET [11129]

Facility

$0.19

Service Code	NDC 0527-1301-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
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

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 00000-1053-51
Hospital Charge Code	901700004
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

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 0000-1139-14
Hospital Charge Code	901700004
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

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 00000-1053-51
Hospital Charge Code	901700004
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

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 0000-1139-14
Hospital Charge Code	901700004
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1069-57
Hospital Charge Code	901700004
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1069-57
Hospital Charge Code	901700004
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1139-16
Hospital Charge Code	901700004
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1139-16
Hospital Charge Code	901700004
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1075-01
Hospital Charge Code	901700004
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1139-17
Hospital Charge Code	901700004
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1139-17
Hospital Charge Code	901700004
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1075-01
Hospital Charge Code	901700004
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

PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION [4080471]

Facility

$0.01

Service Code	NDC 0000-1139-19
Hospital Charge Code	901700004
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

PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION [4080471]

Facility

$0.01

Service Code	NDC 0000-1139-19
Hospital Charge Code	901700004
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1139-15
Hospital Charge Code	901700004
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1053-53
Hospital Charge Code	901700004
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1053-53
Hospital Charge Code	901700004
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1139-15
Hospital Charge Code	901700004
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

PROBENECID 500 MG TABLET [6561]

Facility

$0.71

Service Code	NDC 0591-5347-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
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

PROBENECID 500 MG TABLET [6561]

Facility

$0.71

Service Code	NDC 0591-5347-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

PROCAINAMIDE 100 MG/ML INJECTION SOLUTION [6562]

Facility

$72.00

Service Code	HCPCS J2690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$57.60
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$27.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$57.60
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Health Smart Auto/Commercial	$29.51
Rate for Payer: LLUH Dept of Risk Management WC	$27.05
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$36.88
Rate for Payer: Multiplan Commercial	$54.00

PROCAINAMIDE 100 MG/ML INJECTION SOLUTION [6562]

Facility

$49.18

Service Code	HCPCS J2690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$27.05
Max. Negotiated Rate	$39.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA Government/Medicare	$43.20
Rate for Payer: Aetna of CA Government/Medicare	$29.51
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$27.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$57.60
Rate for Payer: Health Smart Auto/Commercial	$29.51
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$27.05
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$54.00
Rate for Payer: Multiplan Commercial	$36.88

PROCAINAMIDE 500 MG/ML INJECTION SOLUTION [6563]

Facility

$360.00

Service Code	HCPCS J2690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$288.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$288.00
Rate for Payer: Health Smart Auto/Commercial	$216.00
Rate for Payer: LLUH Dept of Risk Management WC	$198.00
Rate for Payer: Multiplan Commercial	$270.00

PROCAINAMIDE 500 MG/ML INJECTION SOLUTION [6563]

Facility

$360.00

Service Code	HCPCS J2690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$288.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$216.00
Rate for Payer: Aetna of CA Government/Medicare	$216.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$288.00
Rate for Payer: Health Smart Auto/Commercial	$216.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$216.00
Rate for Payer: LLUH Dept of Risk Management WC	$198.00
Rate for Payer: Multiplan Commercial	$270.00

Know your out-of-pocket cost for care.

All Charges