Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 51672-5296-1
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 0713-0536-12
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 0713-0536-12
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$8.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 51672-5296-1
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$8.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 0713-0536-06
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$8.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 51672-5296-5
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$11.70

Service Code	NDC 0713-0536-06
Hospital Charge Code	1748042
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$0.54

Service Code	NDC 68084-154-11
Hospital Charge Code	1710621
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$0.54

Service Code	NDC 68084-154-11
Hospital Charge Code	1710621
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$0.07

Service Code	NDC 10702-002-01
Hospital Charge Code	1710621
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$0.14

Service Code	NDC 68001-161-00
Hospital Charge Code	1710621
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

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$0.07

Service Code	NDC 10702-002-01
Hospital Charge Code	1710621
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$0.14

Service Code	NDC 68001-161-00
Hospital Charge Code	1710621
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

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

$2.22

Service Code	CPT J2550
Hospital Charge Code	1720455
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.33
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.33
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.66

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

$2.22

Service Code	CPT J2550
Hospital Charge Code	1720455
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.78
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Cigna of CA HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.66

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$11.70

Service Code	NDC 0713-0526-12
Hospital Charge Code	1748049
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$11.70

Service Code	NDC 51672-5297-1
Hospital Charge Code	1748049
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$8.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$11.70

Service Code	NDC 0713-0526-12
Hospital Charge Code	1748049
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$8.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$11.70

Service Code	NDC 45802-759-30
Hospital Charge Code	1748049
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$8.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$11.70

Service Code	NDC 45802-759-30
Hospital Charge Code	1748049
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$11.70

Service Code	NDC 51672-5297-1
Hospital Charge Code	1748049
Hospital Revenue Code	259
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$5.27
Rate for Payer: Cigna of CA HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.78

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.14

Service Code	CPT Q0169
Hospital Charge Code	1710643
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 EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
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: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

PROMETHAZINE 25 MG TABLET [6622]

Facility

$0.50

Service Code	CPT Q0169
Hospital Charge Code	1710643
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$47.21

Service Code	NDC 40085-220-12
Hospital Charge Code	1748046
Hospital Revenue Code	259
Min. Negotiated Rate	$25.97
Max. Negotiated Rate	$35.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.33
Rate for Payer: Aetna of CA Government/Medicare	$28.33
Rate for Payer: Cash Price	$21.24
Rate for Payer: Health Smart Auto/Commercial	$28.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.33
Rate for Payer: LLUH Dept of Risk Management WC	$25.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.41

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$32.19

Service Code	NDC 0713-0132-12
Hospital Charge Code	1748046
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$24.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.31
Rate for Payer: Aetna of CA Government/Medicare	$19.31
Rate for Payer: Cash Price	$14.49
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.14

Know your out-of-pocket cost for care.

All Charges