Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$2.01

Service Code	NDC 60687-275-62
Hospital Charge Code	NDG119683
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.51

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$1.92

Service Code	NDC 66689-036-01
Hospital Charge Code	NDG119683
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$1.92

Service Code	NDC 66689-036-01
Hospital Charge Code	NDG119683
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]

Facility

$1.47

Service Code	NDC 66689-036-50
Hospital Charge Code	NDG119683
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.10

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.14

Service Code	NDC 9999-9379-93
Hospital Charge Code	NDG6255
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	$0.06
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 Beech St/Commercial/PHCS	$0.11

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.12

Service Code	NDC 51672-4069-1
Hospital Charge Code	1715499
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.12

Service Code	NDC 51672-4069-1
Hospital Charge Code	1715499
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [6255]

Facility

$0.14

Service Code	NDC 9999-9379-93
Hospital Charge Code	NDG6255
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.80

Service Code	NDC 60687-156-95
Hospital Charge Code	1710125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$0.51

Service Code	NDC 51672-4146-1
Hospital Charge Code	1710125
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

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.80

Service Code	NDC 0071-0007-24
Hospital Charge Code	1710125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$0.51

Service Code	NDC 51672-4146-1
Hospital Charge Code	1710125
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

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.80

Service Code	NDC 60687-156-95
Hospital Charge Code	1710125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

PHENYTOIN 50 MG CHEWABLE TABLET [11018]

Facility

$1.80

Service Code	NDC 0071-0007-24
Hospital Charge Code	1710125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]

Facility

$2.08

Service Code	CPT J1165
Hospital Charge Code	1720098
Hospital Revenue Code	636
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$1.25
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]

Facility

$2.08

Service Code	CPT J1165
Hospital Charge Code	1720098
Hospital Revenue Code	636
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$0.94
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Cigna of CA HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]

Facility

$1.20

Service Code	CPT J1165
Hospital Charge Code	1720104
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]

Facility

$1.20

Service Code	CPT J1165
Hospital Charge Code	1720104
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.62

Service Code	NDC 51672-4111-1
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.36

Service Code	NDC 65162-212-10
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.64

Service Code	NDC 68084-376-11
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
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	$0.29
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 Beech St/Commercial/PHCS	$0.48

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.36

Service Code	NDC 65162-212-10
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.64

Service Code	NDC 68084-376-11
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.48

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.64

Service Code	NDC 68084-376-01
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
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	$0.29
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 Beech St/Commercial/PHCS	$0.48

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]

Facility

$0.64

Service Code	NDC 68084-376-01
Hospital Charge Code	1710147
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.48

Know your out-of-pocket cost for care.

All Charges