Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$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 30 MG CAPSULE [11019]

Facility

$1.66

Service Code	NDC 0071-3740-66
Hospital Charge Code	1710163
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna of CA HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]

Facility

$1.66

Service Code	NDC 0071-3740-66
Hospital Charge Code	1710163
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.00
Rate for Payer: Aetna of CA Government/Medicare	$1.00
Rate for Payer: Cash Price	$0.75
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

PHOS-NAK ORAL SOLN CMPND 25 MG/ML (0.8 MMOL/ML) [4080310]

Facility

$0.04

Service Code	NDC 9994-0803-10
Hospital Charge Code	NDG2867
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.02
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	$0.03

PHOS-NAK ORAL SOLN CMPND 25 MG/ML (0.8 MMOL/ML) [4080310]

Facility

$0.04

Service Code	NDC 9994-0803-10
Hospital Charge Code	NDG2867
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
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	$0.03

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-05
Hospital Charge Code	NDG212681
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

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-06
Hospital Charge Code	NDG212681
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

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-05
Hospital Charge Code	NDG212681
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

PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]

Facility

$0.01

Service Code	NDC 24571-116-06
Hospital Charge Code	NDG212681
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

PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]

Facility

$0.01

Service Code	NDC 24571-117-05
Hospital Charge Code	NDG212682
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

PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]

Facility

$0.01

Service Code	NDC 24571-117-05
Hospital Charge Code	NDG212682
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

PHOSPHORATED CARBOHYDRATE ORAL SOLUTION [11022]

Facility

$0.03

Service Code	NDC 1093939933
Hospital Charge Code	1719016
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

PHOSPHORATED CARBOHYDRATE ORAL SOLUTION [11022]

Facility

$0.03

Service Code	NDC 1093939933
Hospital Charge Code	1719016
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

PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION [6270]

Facility

$46.97

Service Code	NDC 17478-510-02
Hospital Charge Code	1720007
Hospital Revenue Code	250
Min. Negotiated Rate	$25.83
Max. Negotiated Rate	$37.58
Rate for Payer: Cash Price	$21.14
Rate for Payer: Cigna of CA HMO/PPO	$37.58
Rate for Payer: Health Smart Auto/Commercial	$28.18
Rate for Payer: LLUH Dept of Risk Management WC	$25.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.23

PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION [6270]

Facility

$46.97

Service Code	NDC 17478-510-02
Hospital Charge Code	1720007
Hospital Revenue Code	250
Min. Negotiated Rate	$25.83
Max. Negotiated Rate	$35.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.18
Rate for Payer: Aetna of CA Government/Medicare	$28.18
Rate for Payer: Cash Price	$21.14
Rate for Payer: Health Smart Auto/Commercial	$28.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.18
Rate for Payer: LLUH Dept of Risk Management WC	$25.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.23

PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]

Facility

$58.76

Service Code	CPT J3430
Hospital Charge Code	1720131
Hospital Revenue Code	636
Min. Negotiated Rate	$32.32
Max. Negotiated Rate	$47.01
Rate for Payer: Cash Price	$26.44
Rate for Payer: Cash Price	$23.09
Rate for Payer: Cigna of CA HMO/PPO	$41.06
Rate for Payer: Cigna of CA HMO/PPO	$47.01
Rate for Payer: Health Smart Auto/Commercial	$30.79
Rate for Payer: Health Smart Auto/Commercial	$35.26
Rate for Payer: LLUH Dept of Risk Management WC	$32.32
Rate for Payer: LLUH Dept of Risk Management WC	$28.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.07

PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]

Facility

$51.32

Service Code	CPT J3430
Hospital Charge Code	1720131
Hospital Revenue Code	636
Min. Negotiated Rate	$28.23
Max. Negotiated Rate	$38.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.26
Rate for Payer: Aetna of CA Government/Medicare	$30.79
Rate for Payer: Aetna of CA Government/Medicare	$35.26
Rate for Payer: Cash Price	$26.44
Rate for Payer: Cash Price	$23.09
Rate for Payer: Health Smart Auto/Commercial	$30.79
Rate for Payer: Health Smart Auto/Commercial	$35.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.26
Rate for Payer: LLUH Dept of Risk Management WC	$28.23
Rate for Payer: LLUH Dept of Risk Management WC	$32.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.49

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]

Facility

$11.39

Service Code	CPT J3430
Hospital Charge Code	NDG110478
Hospital Revenue Code	636
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$8.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.83
Rate for Payer: Aetna of CA Government/Medicare	$6.83
Rate for Payer: Cash Price	$5.13
Rate for Payer: Health Smart Auto/Commercial	$6.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.83
Rate for Payer: LLUH Dept of Risk Management WC	$6.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.54

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]

Facility

$11.39

Service Code	CPT J3430
Hospital Charge Code	NDG110478
Hospital Revenue Code	636
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$9.11
Rate for Payer: Cash Price	$5.13
Rate for Payer: Cigna of CA HMO/PPO	$9.11
Rate for Payer: Health Smart Auto/Commercial	$6.83
Rate for Payer: LLUH Dept of Risk Management WC	$6.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.54

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]

Facility

$59.35

Service Code	CPT J3430
Hospital Charge Code	1720082
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$44.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.61
Rate for Payer: Aetna of CA Government/Medicare	$35.61
Rate for Payer: Cash Price	$26.71
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.51

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]

Facility

$59.35

Service Code	CPT J3430
Hospital Charge Code	1720082
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$47.48
Rate for Payer: Cash Price	$26.71
Rate for Payer: Cigna of CA HMO/PPO	$47.48
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.51

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]

Facility

$59.35

Service Code	CPT J3430
Hospital Charge Code	1720082
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$47.48
Rate for Payer: Cash Price	$26.71
Rate for Payer: Cigna of CA HMO/PPO	$47.48
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.51

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]

Facility

$59.35

Service Code	CPT J3430
Hospital Charge Code	1720082
Hospital Revenue Code	636
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$44.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.61
Rate for Payer: Aetna of CA Government/Medicare	$35.61
Rate for Payer: Cash Price	$26.71
Rate for Payer: Health Smart Auto/Commercial	$35.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.61
Rate for Payer: LLUH Dept of Risk Management WC	$32.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.51

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$33.76

Service Code	NDC 70710-1014-3
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$18.57
Max. Negotiated Rate	$27.01
Rate for Payer: Cash Price	$15.19
Rate for Payer: Cigna of CA HMO/PPO	$27.01
Rate for Payer: Health Smart Auto/Commercial	$20.26
Rate for Payer: LLUH Dept of Risk Management WC	$18.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.32

PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]

Facility

$80.85

Service Code	NDC 60687-381-94
Hospital Charge Code	1710433
Hospital Revenue Code	259
Min. Negotiated Rate	$44.47
Max. Negotiated Rate	$64.68
Rate for Payer: Cash Price	$36.38
Rate for Payer: Cigna of CA HMO/PPO	$64.68
Rate for Payer: Health Smart Auto/Commercial	$48.51
Rate for Payer: LLUH Dept of Risk Management WC	$44.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.64

Know your out-of-pocket cost for care.

All Charges