Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

$0.02

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: 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	$0.02
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	$0.02

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885815
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
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: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885815
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

PYRIDOXINE (VITAMIN B6) ORAL SOLUTION COMPOUND 1 MG/ML [4081140]

Facility

$19.88

Service Code	NDC 9994-0811-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$15.90
Rate for Payer: Cash Price	$10.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.90
Rate for Payer: Health Smart Auto/Commercial	$11.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.93
Rate for Payer: Multiplan Commercial	$14.91

PYRIDOXINE (VITAMIN B6) ORAL SOLUTION COMPOUND 1 MG/ML [4081140]

Facility

$19.88

Service Code	NDC 9994-0811-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$15.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.93
Rate for Payer: Aetna of CA Government/Medicare	$11.93
Rate for Payer: Cash Price	$10.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.90
Rate for Payer: Health Smart Auto/Commercial	$11.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.93
Rate for Payer: Multiplan Commercial	$14.91

PYRIMETHAMINE 25 MG TABLET [11246]

Facility

$307.80

Service Code	NDC 0480-3720-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$169.29
Max. Negotiated Rate	$246.24
Rate for Payer: Cash Price	$169.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$246.24
Rate for Payer: Health Smart Auto/Commercial	$184.68
Rate for Payer: LLUH Dept of Risk Management WC	$169.29
Rate for Payer: Multiplan Commercial	$230.85

PYRIMETHAMINE 25 MG TABLET [11246]

Facility

$307.80

Service Code	NDC 0480-3720-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$169.29
Max. Negotiated Rate	$246.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$184.68
Rate for Payer: Aetna of CA Government/Medicare	$184.68
Rate for Payer: Cash Price	$169.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$246.24
Rate for Payer: Health Smart Auto/Commercial	$184.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$184.68
Rate for Payer: LLUH Dept of Risk Management WC	$169.29
Rate for Payer: Multiplan Commercial	$230.85

PYRIMETHAMINE ORAL SOLUTION COMPOUND 2 MG/ML [4080328]

Facility

$0.09

Service Code	NDC 9994-0803-28
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

PYRIMETHAMINE ORAL SOLUTION COMPOUND 2 MG/ML [4080328]

Facility

$0.09

Service Code	NDC 9994-0803-28
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

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.64

Service Code	NDC 60687-349-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.14

Service Code	NDC 16729-147-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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	$0.08
Rate for Payer: Multiplan Commercial	$0.11

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.56

Service Code	NDC 0904-6640-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.64

Service Code	NDC 60687-349-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.64

Service Code	NDC 60687-349-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.64

Service Code	NDC 60687-349-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.09

Service Code	NDC 67877-250-01
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

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.38

Service Code	NDC 47335-904-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.56

Service Code	NDC 0904-6640-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.09

Service Code	NDC 67877-250-01
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

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.38

Service Code	NDC 47335-904-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.14

Service Code	NDC 16729-147-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

QUETIAPINE 200 MG TABLET [21825]

Facility

$0.20

Service Code	NDC 16571-720-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

QUETIAPINE 200 MG TABLET [21825]

Facility

$0.20

Service Code	NDC 16571-720-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

QUETIAPINE 200 MG TABLET [21825]

Facility

$0.72

Service Code	NDC 47335-905-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
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	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
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	$0.40
Rate for Payer: Multiplan Commercial	$0.54

Know your out-of-pocket cost for care.

All Charges