Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]

Facility

$0.25

Service Code	NDC 5032300602
Hospital Charge Code	1740322
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]

Facility

$0.26

Service Code	NDC 0225-0800-47
Hospital Charge Code	1740322
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.25

Service Code	NDC 69536-050-15
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.25

Service Code	NDC 5032300603
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.25

Service Code	NDC 69536-050-15
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.25

Service Code	NDC 5032300603
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.27

Service Code	NDC 69536-050-21
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.26

Service Code	NDC 0225-0805-47
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.27

Service Code	NDC 69536-050-21
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.26

Service Code	NDC 0225-0805-47
Hospital Charge Code	1740115
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS [4086242]

Facility

$4.80

Service Code	CPT J2371
Hospital Charge Code	1757471
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cigna of CA HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS [4086242]

Facility

$5.19

Service Code	CPT J2371
Hospital Charge Code	NDG6242
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$4.15
Rate for Payer: Cash Price	$2.34
Rate for Payer: Cigna of CA HMO/PPO	$4.15
Rate for Payer: Health Smart Auto/Commercial	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$2.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.89

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS [4086242]

Facility

$4.80

Service Code	CPT J2371
Hospital Charge Code	1757471
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$2.16
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS [4086242]

Facility

$5.19

Service Code	CPT J2371
Hospital Charge Code	NDG6242
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$3.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.11
Rate for Payer: Aetna of CA Government/Medicare	$3.11
Rate for Payer: Cash Price	$2.34
Rate for Payer: Health Smart Auto/Commercial	$3.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$2.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.89

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS (NICU,MCG) [4086243]

Facility

$4.80

Service Code	CPT J2371
Hospital Charge Code	1757471
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$2.16
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS (NICU,MCG) [4086243]

Facility

$4.80

Service Code	CPT J2371
Hospital Charge Code	1757471
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cigna of CA HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS (NICU,MCG) [4086243]

Facility

$5.19

Service Code	CPT J2371
Hospital Charge Code	NDG6242
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$4.15
Rate for Payer: Cigna of CA HMO/PPO	$4.15
Rate for Payer: Health Smart Auto/Commercial	$3.11
Rate for Payer: Cash Price	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.89

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS (NICU,MCG) [4086243]

Facility

$5.19

Service Code	CPT J2371
Hospital Charge Code	NDG6242
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$3.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.11
Rate for Payer: Aetna of CA Government/Medicare	$3.11
Rate for Payer: Cash Price	$2.34
Rate for Payer: Health Smart Auto/Commercial	$3.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$2.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.89

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION (RAD) [40862421]

Facility

$5.30

Service Code	CPT J2371
Hospital Charge Code	1720922
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.24
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION (RAD) [40862421]

Facility

$5.30

Service Code	CPT J2371
Hospital Charge Code	1720922
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.18
Rate for Payer: Aetna of CA Government/Medicare	$3.18
Rate for Payer: Cash Price	$2.39
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION (RAD) [40862421]

Facility

$3.07

Service Code	CPT J2371
Hospital Charge Code	1757471
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Cash Price	$1.38
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cigna of CA HMO/PPO	$2.46
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Cigna of CA HMO/PPO	$3.84
Rate for Payer: Cigna of CA HMO/PPO	$3.07
Rate for Payer: Cigna of CA HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.30

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION (RAD) [40862421]

Facility

$4.40

Service Code	CPT J2371
Hospital Charge Code	1757471
Hospital Revenue Code	636
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$1.84
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cash Price	$1.38
Rate for Payer: Cash Price	$1.98
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.88

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [121306]

Facility

$0.75

Service Code	CPT J2371
Hospital Charge Code	1722047
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Cash Price	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [121306]

Facility

$0.75

Service Code	CPT J2371
Hospital Charge Code	1722047
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of CA HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]

Facility

$2.24

Service Code	CPT J2371
Hospital Charge Code	NDC121306
Hospital Revenue Code	636
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna of CA HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.68

Know your out-of-pocket cost for care.

All Charges