Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$0.80

Service Code	NDC 13517-112-01
Hospital Charge Code	1730198
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$0.80

Service Code	NDC 13517-112-01
Hospital Charge Code	1730198
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$0.81

Service Code	NDC 51293-627-01
Hospital Charge Code	1730198
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$0.81

Service Code	NDC 51293-627-01
Hospital Charge Code	1730198
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$0.80

Service Code	NDC 16571-667-01
Hospital Charge Code	1730198
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

PHENOBARBITAL 64.8 MG TABLET [6219]

Facility

$0.80

Service Code	NDC 16571-667-01
Hospital Charge Code	1730198
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

PHENOBARBITAL 97.2 MG TABLET [6220]

Facility

$1.14

Service Code	NDC 16571-668-01
Hospital Charge Code	1730199
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.91
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.86

PHENOBARBITAL 97.2 MG TABLET [6220]

Facility

$1.14

Service Code	NDC 16571-668-01
Hospital Charge Code	1730199
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.86

PHENOBARBITAL ORAL SOLUTION (IV FORM) 65 MG/ML [4081110]

Facility

$1.63

Service Code	NDC 9994-0811-10
Hospital Charge Code	NDC4081110
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.98
Rate for Payer: Aetna of CA Government/Medicare	$0.98
Rate for Payer: Cash Price	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.22

PHENOBARBITAL ORAL SOLUTION (IV FORM) 65 MG/ML [4081110]

Facility

$1.63

Service Code	NDC 9994-0811-10
Hospital Charge Code	NDC4081110
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.30
Rate for Payer: Cash Price	$0.73
Rate for Payer: Cigna of CA HMO/PPO	$1.30
Rate for Payer: Health Smart Auto/Commercial	$0.98
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.22

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$26.18

Service Code	NDC 42494-415-25
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$20.94
Rate for Payer: Cash Price	$11.78
Rate for Payer: Cigna of CA HMO/PPO	$20.94
Rate for Payer: Health Smart Auto/Commercial	$15.71
Rate for Payer: LLUH Dept of Risk Management WC	$14.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.64

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$26.18

Service Code	NDC 42494-415-01
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$19.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.71
Rate for Payer: Aetna of CA Government/Medicare	$15.71
Rate for Payer: Cash Price	$11.78
Rate for Payer: Health Smart Auto/Commercial	$15.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.71
Rate for Payer: LLUH Dept of Risk Management WC	$14.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.64

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$31.63

Service Code	NDC 0641-0476-21
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$23.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.98
Rate for Payer: Aetna of CA Government/Medicare	$18.98
Rate for Payer: Cash Price	$14.23
Rate for Payer: Health Smart Auto/Commercial	$18.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$17.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.72

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$31.63

Service Code	NDC 0641-0476-25
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$23.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.98
Rate for Payer: Aetna of CA Government/Medicare	$18.98
Rate for Payer: Cash Price	$14.23
Rate for Payer: Health Smart Auto/Commercial	$18.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$17.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.72

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$26.18

Service Code	NDC 42494-415-25
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$19.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.71
Rate for Payer: Aetna of CA Government/Medicare	$15.71
Rate for Payer: Cash Price	$11.78
Rate for Payer: Health Smart Auto/Commercial	$15.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.71
Rate for Payer: LLUH Dept of Risk Management WC	$14.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.64

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$31.63

Service Code	NDC 0641-0476-25
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$25.30
Rate for Payer: Cash Price	$14.23
Rate for Payer: Cigna of CA HMO/PPO	$25.30
Rate for Payer: Health Smart Auto/Commercial	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$17.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.72

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$31.63

Service Code	NDC 0641-0476-21
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$25.30
Rate for Payer: Cash Price	$14.23
Rate for Payer: Cigna of CA HMO/PPO	$25.30
Rate for Payer: Health Smart Auto/Commercial	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$17.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.72

PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]

Facility

$26.18

Service Code	NDC 42494-415-01
Hospital Charge Code	1720211
Hospital Revenue Code	636
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$20.94
Rate for Payer: Cash Price	$11.78
Rate for Payer: Cigna of CA HMO/PPO	$20.94
Rate for Payer: Health Smart Auto/Commercial	$15.71
Rate for Payer: LLUH Dept of Risk Management WC	$14.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.64

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.03

Service Code	NDC 7811201103
Hospital Charge Code	1743517
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

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.02

Service Code	NDC 0904-6305-21
Hospital Charge Code	1743517
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
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	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.02

Service Code	NDC 0536-1228-58
Hospital Charge Code	1743517
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: 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

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.01

Service Code	NDC 46122-749-76
Hospital Charge Code	1743517
Hospital Revenue Code	259
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

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.01

Service Code	NDC 46122-749-76
Hospital Charge Code	1743517
Hospital Revenue Code	259
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

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.03

Service Code	NDC 7811201103
Hospital Charge Code	1743517
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$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: 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

PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]

Facility

$0.02

Service Code	NDC 0536-1228-58
Hospital Charge Code	1743517
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
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	$0.01
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