Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PEMIGATINIB 4.5 MG TABLET [227741]

Facility

$1,500.86

Service Code	NDC 50881-026-01
Hospital Charge Code	ERX227741
Hospital Revenue Code	259
Min. Negotiated Rate	$825.47
Max. Negotiated Rate	$1,200.69
Rate for Payer: Cash Price	$675.39
Rate for Payer: Cigna of CA HMO/PPO	$1,200.69
Rate for Payer: Health Smart Auto/Commercial	$900.52
Rate for Payer: LLUH Dept of Risk Management WC	$825.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,125.64

PEMIGATINIB 9 MG TABLET [227742]

Facility

$1,500.86

Service Code	NDC 50881-027-01
Hospital Charge Code	ERX227742
Hospital Revenue Code	259
Min. Negotiated Rate	$825.47
Max. Negotiated Rate	$1,200.69
Rate for Payer: Cash Price	$675.39
Rate for Payer: Cigna of CA HMO/PPO	$1,200.69
Rate for Payer: Health Smart Auto/Commercial	$900.52
Rate for Payer: LLUH Dept of Risk Management WC	$825.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,125.64

PEMIGATINIB 9 MG TABLET [227742]

Facility

$1,500.86

Service Code	NDC 50881-027-01
Hospital Charge Code	ERX227742
Hospital Revenue Code	259
Min. Negotiated Rate	$825.47
Max. Negotiated Rate	$1,125.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$900.52
Rate for Payer: Aetna of CA Government/Medicare	$900.52
Rate for Payer: Cash Price	$675.39
Rate for Payer: Health Smart Auto/Commercial	$900.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$900.52
Rate for Payer: LLUH Dept of Risk Management WC	$825.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,125.64

PENICILLAMINE 250 MG CAPSULE [10894]

Facility

$314.26

Service Code	NDC 25010-705-15
Hospital Charge Code	1710800
Hospital Revenue Code	259
Min. Negotiated Rate	$172.84
Max. Negotiated Rate	$235.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$188.56
Rate for Payer: Aetna of CA Government/Medicare	$188.56
Rate for Payer: Cash Price	$141.42
Rate for Payer: Health Smart Auto/Commercial	$188.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$188.56
Rate for Payer: LLUH Dept of Risk Management WC	$172.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$235.70

PENICILLAMINE 250 MG CAPSULE [10894]

Facility

$314.26

Service Code	NDC 25010-705-15
Hospital Charge Code	1710800
Hospital Revenue Code	259
Min. Negotiated Rate	$172.84
Max. Negotiated Rate	$251.41
Rate for Payer: Cash Price	$141.42
Rate for Payer: Cigna of CA HMO/PPO	$251.41
Rate for Payer: Health Smart Auto/Commercial	$188.56
Rate for Payer: LLUH Dept of Risk Management WC	$172.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$235.70

PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]

Facility

$1.75

Service Code	NDC 9994-0803-16
Hospital Charge Code	1715235
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.40
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cigna of CA HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.31

PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]

Facility

$1.75

Service Code	NDC 9994-0803-16
Hospital Charge Code	1715235
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.05
Rate for Payer: Aetna of CA Government/Medicare	$1.05
Rate for Payer: Cash Price	$0.79
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.31

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]

Facility

$151.23

Service Code	CPT J0561
Hospital Charge Code	1721205
Hospital Revenue Code	636
Min. Negotiated Rate	$83.18
Max. Negotiated Rate	$113.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.74
Rate for Payer: Aetna of CA Government/Medicare	$90.74
Rate for Payer: Cash Price	$68.05
Rate for Payer: Health Smart Auto/Commercial	$90.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.74
Rate for Payer: LLUH Dept of Risk Management WC	$83.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$113.42

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]

Facility

$151.23

Service Code	CPT J0561
Hospital Charge Code	1721205
Hospital Revenue Code	636
Min. Negotiated Rate	$83.18
Max. Negotiated Rate	$120.98
Rate for Payer: Cash Price	$68.05
Rate for Payer: Cigna of CA HMO/PPO	$120.98
Rate for Payer: Health Smart Auto/Commercial	$90.74
Rate for Payer: LLUH Dept of Risk Management WC	$83.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$113.42

PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]

Facility

$154.95

Service Code	CPT J0561
Hospital Charge Code	1721206
Hospital Revenue Code	636
Min. Negotiated Rate	$85.22
Max. Negotiated Rate	$116.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$92.97
Rate for Payer: Aetna of CA Government/Medicare	$92.97
Rate for Payer: Cash Price	$69.73
Rate for Payer: Health Smart Auto/Commercial	$92.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$92.97
Rate for Payer: LLUH Dept of Risk Management WC	$85.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$116.21

PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]

Facility

$154.95

Service Code	CPT J0561
Hospital Charge Code	1721206
Hospital Revenue Code	636
Min. Negotiated Rate	$85.22
Max. Negotiated Rate	$123.96
Rate for Payer: Cash Price	$69.73
Rate for Payer: Cigna of CA HMO/PPO	$123.96
Rate for Payer: Health Smart Auto/Commercial	$92.97
Rate for Payer: LLUH Dept of Risk Management WC	$85.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$116.21

PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]

Facility

$174.64

Service Code	CPT J0561
Hospital Charge Code	1721204
Hospital Revenue Code	636
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$139.71
Rate for Payer: Cash Price	$78.59
Rate for Payer: Cigna of CA HMO/PPO	$139.71
Rate for Payer: Health Smart Auto/Commercial	$104.78
Rate for Payer: LLUH Dept of Risk Management WC	$96.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$130.98

PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]

Facility

$174.64

Service Code	CPT J0561
Hospital Charge Code	1721204
Hospital Revenue Code	636
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$130.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$104.78
Rate for Payer: Aetna of CA Government/Medicare	$104.78
Rate for Payer: Cash Price	$78.59
Rate for Payer: Health Smart Auto/Commercial	$104.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$104.78
Rate for Payer: LLUH Dept of Risk Management WC	$96.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$130.98

PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]

Facility

$120.55

Service Code	CPT J0558
Hospital Charge Code	1721202
Hospital Revenue Code	636
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$90.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.33
Rate for Payer: Aetna of CA Government/Medicare	$72.33
Rate for Payer: Cash Price	$54.25
Rate for Payer: Health Smart Auto/Commercial	$72.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.33
Rate for Payer: LLUH Dept of Risk Management WC	$66.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.41

PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]

Facility

$120.55

Service Code	CPT J0558
Hospital Charge Code	1721202
Hospital Revenue Code	636
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$96.44
Rate for Payer: Cash Price	$54.25
Rate for Payer: Cigna of CA HMO/PPO	$96.44
Rate for Payer: Health Smart Auto/Commercial	$72.33
Rate for Payer: LLUH Dept of Risk Management WC	$66.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.41

PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]

Facility

$59.99

Service Code	CPT J2540
Hospital Charge Code	ERX6085
Hospital Revenue Code	636
Min. Negotiated Rate	$32.99
Max. Negotiated Rate	$44.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.64
Rate for Payer: Aetna of CA Government/Medicare	$35.99
Rate for Payer: Aetna of CA Government/Medicare	$36.64
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.48
Rate for Payer: Health Smart Auto/Commercial	$35.99
Rate for Payer: Health Smart Auto/Commercial	$36.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.64
Rate for Payer: LLUH Dept of Risk Management WC	$33.58
Rate for Payer: LLUH Dept of Risk Management WC	$32.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.99

PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]

Facility

$61.06

Service Code	CPT J2540
Hospital Charge Code	ERX6085
Hospital Revenue Code	636
Min. Negotiated Rate	$33.58
Max. Negotiated Rate	$48.85
Rate for Payer: Cash Price	$27.48
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna of CA HMO/PPO	$47.99
Rate for Payer: Cigna of CA HMO/PPO	$48.85
Rate for Payer: Health Smart Auto/Commercial	$36.64
Rate for Payer: Health Smart Auto/Commercial	$35.99
Rate for Payer: LLUH Dept of Risk Management WC	$33.58
Rate for Payer: LLUH Dept of Risk Management WC	$32.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.80

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]

Facility

$15.27

Service Code	CPT J2540
Hospital Charge Code	1720421
Hospital Revenue Code	636
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$11.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.14
Rate for Payer: Aetna of CA Government/Medicare	$3.14
Rate for Payer: Aetna of CA Government/Medicare	$9.16
Rate for Payer: Cash Price	$2.35
Rate for Payer: Cash Price	$6.87
Rate for Payer: Health Smart Auto/Commercial	$9.16
Rate for Payer: Health Smart Auto/Commercial	$3.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.16
Rate for Payer: LLUH Dept of Risk Management WC	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$8.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.92

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]

Facility

$5.23

Service Code	CPT J2540
Hospital Charge Code	1720421
Hospital Revenue Code	636
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$4.18
Rate for Payer: Cash Price	$2.35
Rate for Payer: Cash Price	$6.87
Rate for Payer: Cigna of CA HMO/PPO	$12.22
Rate for Payer: Cigna of CA HMO/PPO	$4.18
Rate for Payer: Health Smart Auto/Commercial	$3.14
Rate for Payer: Health Smart Auto/Commercial	$9.16
Rate for Payer: LLUH Dept of Risk Management WC	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$8.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.45

PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]

Facility

$55.29

Service Code	CPT J2540
Hospital Charge Code	ERX6087
Hospital Revenue Code	636
Min. Negotiated Rate	$30.41
Max. Negotiated Rate	$44.23
Rate for Payer: Cash Price	$24.88
Rate for Payer: Cigna of CA HMO/PPO	$44.23
Rate for Payer: Health Smart Auto/Commercial	$33.17
Rate for Payer: LLUH Dept of Risk Management WC	$30.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.47

PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]

Facility

$55.29

Service Code	CPT J2540
Hospital Charge Code	ERX6087
Hospital Revenue Code	636
Min. Negotiated Rate	$30.41
Max. Negotiated Rate	$41.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.17
Rate for Payer: Aetna of CA Government/Medicare	$33.17
Rate for Payer: Cash Price	$24.88
Rate for Payer: Health Smart Auto/Commercial	$33.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.17
Rate for Payer: LLUH Dept of Risk Management WC	$30.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.47

PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]

Facility

$0.08

Service Code	NDC 9994-0815-01
Hospital Charge Code	NDC4081501
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.06

PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]

Facility

$0.08

Service Code	NDC 9994-0815-01
Hospital Charge Code	NDC4081501
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	$0.04
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 Beech St/Commercial/PHCS	$0.06

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]

Facility

$0.08

Service Code	NDC 0093-4127-74
Hospital Charge Code	NDG6091
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.06

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]

Facility

$0.08

Service Code	NDC 0093-4127-74
Hospital Charge Code	NDG6091
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	$0.04
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 Beech St/Commercial/PHCS	$0.06

Know your out-of-pocket cost for care.

All Charges