Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.50

Service Code	NDC 68084-155-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.50

Service Code	NDC 68084-155-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.50

Service Code	NDC 68084-155-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.06

Service Code	NDC 10702-003-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.08

Service Code	NDC 9999-2003-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.06

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.08

Service Code	NDC 9999-2003-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.06

Service Code	NDC 10702-003-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.50

Service Code	NDC 68084-155-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$32.19

Service Code	NDC 0713-0132-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$25.75
Rate for Payer: Cash Price	$17.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.75
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Commercial	$24.14

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$32.19

Service Code	NDC 0713-0132-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$25.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.31
Rate for Payer: Aetna of CA Government/Medicare	$19.31
Rate for Payer: Cash Price	$17.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.75
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Commercial	$24.14

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$32.19

Service Code	NDC 0713-0132-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$25.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.31
Rate for Payer: Aetna of CA Government/Medicare	$19.31
Rate for Payer: Cash Price	$17.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.75
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Commercial	$24.14

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$47.21

Service Code	NDC 40085-220-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.97
Max. Negotiated Rate	$37.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.33
Rate for Payer: Aetna of CA Government/Medicare	$28.33
Rate for Payer: Cash Price	$25.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.77
Rate for Payer: Health Smart Auto/Commercial	$28.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.33
Rate for Payer: LLUH Dept of Risk Management WC	$25.97
Rate for Payer: Multiplan Commercial	$35.41

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$47.21

Service Code	NDC 40085-220-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.97
Max. Negotiated Rate	$37.77
Rate for Payer: Cash Price	$25.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.77
Rate for Payer: Health Smart Auto/Commercial	$28.33
Rate for Payer: LLUH Dept of Risk Management WC	$25.97
Rate for Payer: Multiplan Commercial	$35.41

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$32.19

Service Code	NDC 0713-0132-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$25.75
Rate for Payer: Cash Price	$17.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.75
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Commercial	$24.14

PROMETHAZINE 50 MG TABLET [6623]

Facility

$0.11

Service Code	HCPCS Q0169
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

PROMETHAZINE 50 MG TABLET [6623]

Facility

$0.11

Service Code	HCPCS Q0169
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
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	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
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 Commercial	$0.08

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]

Facility

$0.07

Service Code	HCPCS Q0169
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]

Facility

$0.07

Service Code	HCPCS Q0169
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]

Facility

$0.07

Service Code	NDC 9999-9966-27
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]

Facility

$0.07

Service Code	NDC 9999-9966-27
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]

Facility

$0.09

Service Code	NDC 64679-604-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]

Facility

$0.09

Service Code	NDC 64679-604-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

PROPAFENONE 150 MG TABLET [11146]

Facility

$0.32

Service Code	NDC 62559-230-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

PROPAFENONE 150 MG TABLET [11146]

Facility

$0.32

Service Code	NDC 62559-230-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

PROPAFENONE 225 MG TABLET [11147]

Facility

$1.25

Service Code	NDC 53489-552-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.00
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.94

Know your out-of-pocket cost for care.

All Charges