Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PROPYLTHIOURACIL ORAL SUSPENSION COMPOUND 5 MG/ML [4080325]

Facility

$0.90

Service Code	NDC 9994-0803-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

PROPYLTHIOURACIL ORAL SUSPENSION COMPOUND 5 MG/ML [4080325]

Facility

$0.90

Service Code	NDC 9994-0803-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$3.71

Service Code	HCPCS J2720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.97
Rate for Payer: Cash Price	$2.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.97
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.04
Rate for Payer: Multiplan Commercial	$2.78

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$3.71

Service Code	HCPCS J2720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$2.23
Rate for Payer: Cash Price	$2.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.97
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.04
Rate for Payer: Multiplan Commercial	$2.78

PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID [111029]

Facility

$0.06

Service Code	NDC 50580-536-04
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

PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID [111029]

Facility

$0.06

Service Code	NDC 50580-536-04
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

PSEUDOEPHEDRINE 60 MG TABLET [6715]

Facility

$0.07

Service Code	NDC 0904-6907-06
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

PSEUDOEPHEDRINE 60 MG TABLET [6715]

Facility

$0.07

Service Code	NDC 0904-6907-06
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

PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET [11218]

Facility

$0.44

Service Code	NDC 37000-024-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET [11218]

Facility

$0.44

Service Code	NDC 37000-024-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
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

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-10
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	$0.28
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

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
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

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-04
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	$0.28
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

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.46

Service Code	NDC 70954-484-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$4.37
Rate for Payer: Cash Price	$3.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.37
Rate for Payer: Health Smart Auto/Commercial	$3.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.00
Rate for Payer: Multiplan Commercial	$4.09

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.32

Service Code	NDC 33342-447-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$4.26
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.26
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.93
Rate for Payer: Multiplan Commercial	$3.99

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.46

Service Code	NDC 70954-484-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$4.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.28
Rate for Payer: Aetna of CA Government/Medicare	$3.28
Rate for Payer: Cash Price	$3.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.37
Rate for Payer: Health Smart Auto/Commercial	$3.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.28
Rate for Payer: LLUH Dept of Risk Management WC	$3.00
Rate for Payer: Multiplan Commercial	$4.09

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.42

Service Code	NDC 70954-484-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$4.34
Rate for Payer: Cash Price	$2.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.34
Rate for Payer: Health Smart Auto/Commercial	$3.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.98
Rate for Payer: Multiplan Commercial	$4.07

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$6.96

Service Code	NDC 60687-789-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.18
Rate for Payer: Aetna of CA Government/Medicare	$4.18
Rate for Payer: Cash Price	$3.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.57
Rate for Payer: Health Smart Auto/Commercial	$4.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.18
Rate for Payer: LLUH Dept of Risk Management WC	$3.83
Rate for Payer: Multiplan Commercial	$5.22

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.32

Service Code	NDC 33342-447-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$4.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.26
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.93
Rate for Payer: Multiplan Commercial	$3.99

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$4.40

Service Code	NDC 10135-735-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.52
Rate for Payer: Cash Price	$2.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Commercial	$3.30

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$6.96

Service Code	NDC 60687-789-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.18
Rate for Payer: Aetna of CA Government/Medicare	$4.18
Rate for Payer: Cash Price	$3.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.57
Rate for Payer: Health Smart Auto/Commercial	$4.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.18
Rate for Payer: LLUH Dept of Risk Management WC	$3.83
Rate for Payer: Multiplan Commercial	$5.22

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.42

Service Code	NDC 70954-484-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$4.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.25
Rate for Payer: Aetna of CA Government/Medicare	$3.25
Rate for Payer: Cash Price	$2.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.34
Rate for Payer: Health Smart Auto/Commercial	$3.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.98
Rate for Payer: Multiplan Commercial	$4.07

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$6.96

Service Code	NDC 60687-789-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$5.57
Rate for Payer: Cash Price	$3.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.57
Rate for Payer: Health Smart Auto/Commercial	$4.18
Rate for Payer: LLUH Dept of Risk Management WC	$3.83
Rate for Payer: Multiplan Commercial	$5.22

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$4.40

Service Code	NDC 10135-735-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Cash Price	$2.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Commercial	$3.30

Know your out-of-pocket cost for care.

All Charges