Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 0000-1139-14
Hospital Charge Code	ERX40840046
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

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 00000-1053-51
Hospital Charge Code	ERX40840046
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

PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]

Facility

$0.01

Service Code	NDC 0000-1139-14
Hospital Charge Code	ERX40840046
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1139-16
Hospital Charge Code	ERX40840045
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1069-57
Hospital Charge Code	ERX40840045
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1069-57
Hospital Charge Code	ERX40840045
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

PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]

Facility

$0.01

Service Code	NDC 0000-1139-16
Hospital Charge Code	ERX40840045
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1139-17
Hospital Charge Code	ERX4080470
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1075-01
Hospital Charge Code	ERX4080470
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1139-17
Hospital Charge Code	ERX4080470
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

PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]

Facility

$0.01

Service Code	NDC 0000-1075-01
Hospital Charge Code	ERX4080470
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

PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION [4080471]

Facility

$0.01

Service Code	NDC 0000-1139-19
Hospital Charge Code	ERX4080471
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

PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION [4080471]

Facility

$0.01

Service Code	NDC 0000-1139-19
Hospital Charge Code	ERX4080471
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1139-15
Hospital Charge Code	ERX4080472
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1139-15
Hospital Charge Code	ERX4080472
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1053-53
Hospital Charge Code	ERX4080472
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

PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]

Facility

$0.01

Service Code	NDC 0000-1053-53
Hospital Charge Code	ERX4080472
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

PROBENECID 500 MG TABLET [6561]

Facility

$0.71

Service Code	NDC 0591-5347-01
Hospital Charge Code	1711315
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

PROBENECID 500 MG TABLET [6561]

Facility

$0.71

Service Code	NDC 0591-5347-01
Hospital Charge Code	1711315
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

PROCAINAMIDE 100 MG/ML INJECTION SOLUTION [6562]

Facility

$72.00

Service Code	CPT J2690
Hospital Charge Code	1720209
Hospital Revenue Code	636
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.31
Rate for Payer: Aetna of CA Government/Medicare	$6.31
Rate for Payer: Aetna of CA Government/Medicare	$43.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$4.73
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Health Smart Auto/Commercial	$6.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.31
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$5.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00

PROCAINAMIDE 100 MG/ML INJECTION SOLUTION [6562]

Facility

$72.00

Service Code	CPT J2690
Hospital Charge Code	1720209
Hospital Revenue Code	636
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$57.60
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$4.73
Rate for Payer: Cigna of CA HMO/PPO	$57.60
Rate for Payer: Cigna of CA HMO/PPO	$8.42
Rate for Payer: Health Smart Auto/Commercial	$6.31
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.79
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.89

PROCAINAMIDE 500 MG/ML INJECTION SOLUTION [6563]

Facility

$360.00

Service Code	CPT J2690
Hospital Charge Code	1720217
Hospital Revenue Code	636
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$216.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$26.20
Rate for Payer: Aetna of CA Government/Medicare	$26.20
Rate for Payer: Aetna of CA Government/Medicare	$216.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$19.65
Rate for Payer: Health Smart Auto/Commercial	$26.20
Rate for Payer: Health Smart Auto/Commercial	$216.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$26.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$216.00
Rate for Payer: LLUH Dept of Risk Management WC	$198.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$270.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.74

PROCAINAMIDE 500 MG/ML INJECTION SOLUTION [6563]

Facility

$360.00

Service Code	CPT J2690
Hospital Charge Code	1720217
Hospital Revenue Code	636
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$288.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$19.65
Rate for Payer: Cigna of CA HMO/PPO	$34.93
Rate for Payer: Cigna of CA HMO/PPO	$288.00
Rate for Payer: Health Smart Auto/Commercial	$26.20
Rate for Payer: Health Smart Auto/Commercial	$216.00
Rate for Payer: LLUH Dept of Risk Management WC	$198.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$270.00

PROCAINAMIDE ORAL SOLUTION (IV FORM) 50 MG/ML [4080440]

Facility

$1.29

Service Code	NDC 9994-0804-40
Hospital Charge Code	1715897
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$0.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.97

PROCAINAMIDE ORAL SOLUTION (IV FORM) 50 MG/ML [4080440]

Facility

$1.29

Service Code	NDC 9994-0804-40
Hospital Charge Code	1715897
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.03
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.97

Know your out-of-pocket cost for care.

All Charges