Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.51

Service Code	NDC 60505-0033-6
Hospital Charge Code	1711410
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.51

Service Code	NDC 60505-0033-6
Hospital Charge Code	1711410
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]

Facility

$0.30

Service Code	NDC 0904-5448-61
Hospital Charge Code	1711410
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]

Facility

$0.03

Service Code	NDC 9994-0803-17
Hospital Charge Code	ERX4080317
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.02

PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]

Facility

$0.03

Service Code	NDC 9994-0803-17
Hospital Charge Code	ERX4080317
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: 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 Beech St/Commercial/PHCS	$0.02

PEPPERMINT OIL [6116]

Facility

$0.87

Service Code	NDC 395201591
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

PEPPERMINT OIL [6116]

Facility

$0.87

Service Code	NDC 395201591
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.87

Service Code	NDC 395201591
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.87

Service Code	NDC 395201591
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.32

Service Code	NDC 395224391
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.24

PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]

Facility

$0.32

Service Code	NDC 395224391
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
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	$0.14
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 Beech St/Commercial/PHCS	$0.24

PEPPERMINT SPIRIT ORAL [28205]

Facility

$0.32

Service Code	NDC 395224391
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
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	$0.14
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 Beech St/Commercial/PHCS	$0.24

PEPPERMINT SPIRIT ORAL [28205]

Facility

$0.32

Service Code	NDC 395224391
Hospital Charge Code	1743585
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.24

PERAMPANEL 2 MG TABLET [204501]

Facility

$23.44

Service Code	NDC 62856-272-30
Hospital Charge Code	ERX204501
Hospital Revenue Code	259
Min. Negotiated Rate	$12.89
Max. Negotiated Rate	$18.75
Rate for Payer: Cash Price	$10.55
Rate for Payer: Cigna of CA HMO/PPO	$18.75
Rate for Payer: Health Smart Auto/Commercial	$14.06
Rate for Payer: LLUH Dept of Risk Management WC	$12.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.58

PERAMPANEL 2 MG TABLET [204501]

Facility

$23.44

Service Code	NDC 62856-272-30
Hospital Charge Code	ERX204501
Hospital Revenue Code	259
Min. Negotiated Rate	$12.89
Max. Negotiated Rate	$17.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.06
Rate for Payer: Aetna of CA Government/Medicare	$14.06
Rate for Payer: Cash Price	$10.55
Rate for Payer: Health Smart Auto/Commercial	$14.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.06
Rate for Payer: LLUH Dept of Risk Management WC	$12.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.58

PERAMPANEL 4 MG TABLET [204502]

Facility

$46.32

Service Code	NDC 62856-274-30
Hospital Charge Code	ERX204502
Hospital Revenue Code	259
Min. Negotiated Rate	$25.48
Max. Negotiated Rate	$34.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.79
Rate for Payer: Aetna of CA Government/Medicare	$27.79
Rate for Payer: Cash Price	$20.84
Rate for Payer: Health Smart Auto/Commercial	$27.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.79
Rate for Payer: LLUH Dept of Risk Management WC	$25.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.74

PERAMPANEL 4 MG TABLET [204502]

Facility

$46.32

Service Code	NDC 62856-274-30
Hospital Charge Code	ERX204502
Hospital Revenue Code	259
Min. Negotiated Rate	$25.48
Max. Negotiated Rate	$37.06
Rate for Payer: Cash Price	$20.84
Rate for Payer: Cigna of CA HMO/PPO	$37.06
Rate for Payer: Health Smart Auto/Commercial	$27.79
Rate for Payer: LLUH Dept of Risk Management WC	$25.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.74

PERAMPANEL 6 MG TABLET [204503]

Facility

$46.32

Service Code	NDC 62856-276-30
Hospital Charge Code	ERX204503
Hospital Revenue Code	259
Min. Negotiated Rate	$25.48
Max. Negotiated Rate	$37.06
Rate for Payer: Cash Price	$20.84
Rate for Payer: Cigna of CA HMO/PPO	$37.06
Rate for Payer: Health Smart Auto/Commercial	$27.79
Rate for Payer: LLUH Dept of Risk Management WC	$25.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.74

PERAMPANEL 6 MG TABLET [204503]

Facility

$46.32

Service Code	NDC 62856-276-30
Hospital Charge Code	ERX204503
Hospital Revenue Code	259
Min. Negotiated Rate	$25.48
Max. Negotiated Rate	$34.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.79
Rate for Payer: Aetna of CA Government/Medicare	$27.79
Rate for Payer: Cash Price	$20.84
Rate for Payer: Health Smart Auto/Commercial	$27.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.79
Rate for Payer: LLUH Dept of Risk Management WC	$25.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.74

PERFLUTREN PROTEIN-TYPE A MICROSPHERES 0.22 MG/ML INTRAVENOUS SUSP [82177]

Facility

$56.16

Service Code	CPT Q9956
Hospital Charge Code	NDG82177
Hospital Revenue Code	636
Min. Negotiated Rate	$30.89
Max. Negotiated Rate	$44.93
Rate for Payer: Cash Price	$25.27
Rate for Payer: Cigna of CA HMO/PPO	$44.93
Rate for Payer: Health Smart Auto/Commercial	$33.70
Rate for Payer: LLUH Dept of Risk Management WC	$30.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.12

PERFLUTREN PROTEIN-TYPE A MICROSPHERES 0.22 MG/ML INTRAVENOUS SUSP [82177]

Facility

$56.16

Service Code	CPT Q9956
Hospital Charge Code	NDG82177
Hospital Revenue Code	636
Min. Negotiated Rate	$30.89
Max. Negotiated Rate	$42.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.70
Rate for Payer: Aetna of CA Government/Medicare	$33.70
Rate for Payer: Cash Price	$25.27
Rate for Payer: Health Smart Auto/Commercial	$33.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.70
Rate for Payer: LLUH Dept of Risk Management WC	$30.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.12

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

$0.01

Service Code	NDC 0941-0413-07
Hospital Charge Code	NDG27801A
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

$0.01

Service Code	NDC 0941-0413-01
Hospital Charge Code	1771281
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

$0.01

Service Code	NDC 0941-0413-01
Hospital Charge Code	1771281
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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: 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 Beech St/Commercial/PHCS	$0.01

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

$0.02

Service Code	NDC 0941-0413-04
Hospital Charge Code	NDG27801
Hospital Revenue Code	250
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: 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 Beech St/Commercial/PHCS	$0.02

Know your out-of-pocket cost for care.

All Charges