Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.49

Service Code	NDC 11523-7268-3
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.19
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of CA HMO/PPO	$1.19
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.06

Service Code	NDC 9999-9254-24
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.49

Service Code	NDC 11523-7234-1
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.19
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of CA HMO/PPO	$1.19
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.49

Service Code	NDC 11523-7268-3
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.89
Rate for Payer: Aetna of CA Government/Medicare	$0.89
Rate for Payer: Cash Price	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.49

Service Code	NDC 11523-7234-1
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.89
Rate for Payer: Aetna of CA Government/Medicare	$0.89
Rate for Payer: Cash Price	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.36

Service Code	NDC 11523-7268-8
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.02

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.92

Service Code	NDC 60687-431-99
Hospital Charge Code	1713118
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

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.06

Service Code	NDC 9999-9254-24
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.85
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cigna of CA HMO/PPO	$0.85
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$2.46

Service Code	NDC 45802-868-00
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.06

Service Code	NDC 9999-9321-54
Hospital Charge Code	1719218
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$2.02

Service Code	NDC 60687-431-98
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Cash Price	$0.91
Rate for Payer: Cigna of CA HMO/PPO	$1.62
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	$1.52

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.92

Service Code	NDC 60687-431-92
Hospital Charge Code	1713118
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

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$2.46

Service Code	NDC 45802-868-00
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.97
Rate for Payer: Cash Price	$1.11
Rate for Payer: Cigna of CA HMO/PPO	$1.97
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$2.02

Service Code	NDC 60687-431-98
Hospital Charge Code	1713118
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$0.91
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.52

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]

Facility

$1.92

Service Code	NDC 60687-431-92
Hospital Charge Code	1713118
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

POLYETHYLENE GLYCOL 3350 4.25 GRAM ORAL POWDER PACKET [232762]

Facility

$1.37

Service Code	NDC 17856-0962-2
Hospital Charge Code	ERX232762
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

POLYETHYLENE GLYCOL 3350 4.25 GRAM ORAL POWDER PACKET [232762]

Facility

$1.37

Service Code	NDC 17856-0962-2
Hospital Charge Code	ERX232762
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]

Facility

$0.42

Service Code	NDC 7430001067
Hospital Charge Code	NDG232731
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]

Facility

$0.42

Service Code	NDC 7430001067
Hospital Charge Code	NDG232731
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]

Facility

$1.31

Service Code	NDC 60758-908-10
Hospital Charge Code	1740272
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]

Facility

$9.58

Service Code	NDC 0023-7824-10
Hospital Charge Code	1740272
Hospital Revenue Code	259
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$7.66
Rate for Payer: Cash Price	$4.31
Rate for Payer: Cigna of CA HMO/PPO	$7.66
Rate for Payer: Health Smart Auto/Commercial	$5.75
Rate for Payer: LLUH Dept of Risk Management WC	$5.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.18

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]

Facility

$9.58

Service Code	NDC 0023-7824-10
Hospital Charge Code	1740272
Hospital Revenue Code	259
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$7.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.75
Rate for Payer: Aetna of CA Government/Medicare	$5.75
Rate for Payer: Cash Price	$4.31
Rate for Payer: Health Smart Auto/Commercial	$5.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.75
Rate for Payer: LLUH Dept of Risk Management WC	$5.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.18

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]

Facility

$1.31

Service Code	NDC 60758-908-10
Hospital Charge Code	1740272
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]

Facility

$1.24

Service Code	NDC 61314-628-10
Hospital Charge Code	1740272
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]

Facility

$1.24

Service Code	NDC 61314-628-10
Hospital Charge Code	1740272
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.99
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$0.99
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

Know your out-of-pocket cost for care.

All Charges