Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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 ORAL SUSPENSION COMPOUND 100 MG/ML [4080326]

Facility

$6.32

Service Code	NDC 9994-0803-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$5.06
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.06
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: LLUH Dept of Risk Management WC	$3.48
Rate for Payer: Multiplan Commercial	$4.74

PYRAZINAMIDE ORAL SUSPENSION COMPOUND 100 MG/ML [4080326]

Facility

$6.32

Service Code	NDC 9994-0803-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$5.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.79
Rate for Payer: Aetna of CA Government/Medicare	$3.79
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.06
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.79
Rate for Payer: LLUH Dept of Risk Management WC	$3.48
Rate for Payer: Multiplan Commercial	$4.74

PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]

Facility

$20.25

Service Code	NDC 0781-3040-95
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$11.14
Max. Negotiated Rate	$16.20
Rate for Payer: Cash Price	$11.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.20
Rate for Payer: Health Smart Auto/Commercial	$12.15
Rate for Payer: LLUH Dept of Risk Management WC	$11.14
Rate for Payer: Multiplan Commercial	$15.19

PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]

Facility

$20.25

Service Code	NDC 0781-3040-72
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$11.14
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.15
Rate for Payer: Aetna of CA Government/Medicare	$12.15
Rate for Payer: Cash Price	$11.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.20
Rate for Payer: Health Smart Auto/Commercial	$12.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.15
Rate for Payer: LLUH Dept of Risk Management WC	$11.14
Rate for Payer: Multiplan Commercial	$15.19

PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]

Facility

$20.25

Service Code	NDC 0781-3040-95
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$11.14
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.15
Rate for Payer: Aetna of CA Government/Medicare	$12.15
Rate for Payer: Cash Price	$11.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.20
Rate for Payer: Health Smart Auto/Commercial	$12.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.15
Rate for Payer: LLUH Dept of Risk Management WC	$11.14
Rate for Payer: Multiplan Commercial	$15.19

PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION [11237]

Facility

$20.25

Service Code	NDC 0781-3040-72
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$11.14
Max. Negotiated Rate	$16.20
Rate for Payer: Cash Price	$11.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.20
Rate for Payer: Health Smart Auto/Commercial	$12.15
Rate for Payer: LLUH Dept of Risk Management WC	$11.14
Rate for Payer: Multiplan Commercial	$15.19

PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRUP [11238]

Facility

$4.46

Service Code	NDC 0187-3012-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$3.57
Rate for Payer: Cash Price	$2.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.57
Rate for Payer: Health Smart Auto/Commercial	$2.68
Rate for Payer: LLUH Dept of Risk Management WC	$2.45
Rate for Payer: Multiplan Commercial	$3.35

PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRUP [11238]

Facility

$4.46

Service Code	NDC 0187-3012-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$3.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.68
Rate for Payer: Aetna of CA Government/Medicare	$2.68
Rate for Payer: Cash Price	$2.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.57
Rate for Payer: Health Smart Auto/Commercial	$2.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.68
Rate for Payer: LLUH Dept of Risk Management WC	$2.45
Rate for Payer: Multiplan Commercial	$3.35

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]

Facility

$0.98

Service Code	NDC 0115-3511-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
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	$0.78
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

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]

Facility

$1.22

Service Code	NDC 71930-028-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]

Facility

$1.22

Service Code	NDC 68382-659-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]

Facility

$0.98

Service Code	NDC 0115-3511-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
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

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]

Facility

$1.22

Service Code	NDC 68382-659-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

PYRIDOSTIGMINE BROMIDE 60 MG TABLET [11239]

Facility

$1.22

Service Code	NDC 71930-028-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

PYRIDOXINE ORAL SOLUTION (IV FORM) 100 MG/ML [4080441]

Facility

$10.79

Service Code	NDC 9994-0804-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$8.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.47
Rate for Payer: Aetna of CA Government/Medicare	$6.47
Rate for Payer: Cash Price	$5.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.63
Rate for Payer: Health Smart Auto/Commercial	$6.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.47
Rate for Payer: LLUH Dept of Risk Management WC	$5.93
Rate for Payer: Multiplan Commercial	$8.09

PYRIDOXINE ORAL SOLUTION (IV FORM) 100 MG/ML [4080441]

Facility

$10.79

Service Code	NDC 9994-0804-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$8.63
Rate for Payer: Cash Price	$5.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.63
Rate for Payer: Health Smart Auto/Commercial	$6.47
Rate for Payer: LLUH Dept of Risk Management WC	$5.93
Rate for Payer: Multiplan Commercial	$8.09

PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]

Facility

$26.08

Service Code	HCPCS J3415
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$20.86
Rate for Payer: Cash Price	$14.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.86
Rate for Payer: Health Smart Auto/Commercial	$15.65
Rate for Payer: LLUH Dept of Risk Management WC	$14.34
Rate for Payer: Multiplan Commercial	$19.56

PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]

Facility

$26.08

Service Code	HCPCS J3415
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$20.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.65
Rate for Payer: Aetna of CA Government/Medicare	$15.65
Rate for Payer: Cash Price	$14.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.86
Rate for Payer: Health Smart Auto/Commercial	$15.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.65
Rate for Payer: LLUH Dept of Risk Management WC	$14.34
Rate for Payer: Multiplan Commercial	$19.56

PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]

Facility

$0.03

Service Code	NDC 8770140730
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$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 Commercial	$0.02

PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]

Facility

$0.03

Service Code	NDC 8770140730
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]

Facility

$0.03

Service Code	NDC 0536440601
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$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 Commercial	$0.02

PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]

Facility

$0.03

Service Code	NDC 0536440601
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.02

Service Code	NDC 5789685301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
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	$0.02

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

Know your out-of-pocket cost for care.

All Charges