Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]

Facility

$32.19

Service Code	NDC 0713-0132-06
Hospital Charge Code	1748046
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$24.14
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: Cash Price	$14.49
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: 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

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	$37.77
Rate for Payer: Cash Price	$21.24
Rate for Payer: Cigna of CA HMO/PPO	$37.77
Rate for Payer: Health Smart Auto/Commercial	$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 0713-0132-06
Hospital Charge Code	1748046
Hospital Revenue Code	259
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$25.75
Rate for Payer: Cash Price	$14.49
Rate for Payer: Cigna of CA HMO/PPO	$25.75
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.14

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	$25.75
Rate for Payer: Cash Price	$14.49
Rate for Payer: Cigna of CA HMO/PPO	$25.75
Rate for Payer: Health Smart Auto/Commercial	$19.31
Rate for Payer: LLUH Dept of Risk Management WC	$17.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.14

PROMETHAZINE 50 MG TABLET [6623]

Facility

$0.11

Service Code	CPT Q0169
Hospital Charge Code	1710152
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.10
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

PROMETHAZINE 50 MG TABLET [6623]

Facility

$0.11

Service Code	CPT Q0169
Hospital Charge Code	1710152
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]

Facility

$0.10

Service Code	CPT Q0169
Hospital Charge Code	1715043
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]

Facility

$0.10

Service Code	CPT Q0169
Hospital Charge Code	1715043
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]

Facility

$0.10

Service Code	NDC 60432-606-16
Hospital Charge Code	1715706
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]

Facility

$0.10

Service Code	NDC 60432-606-16
Hospital Charge Code	1715706
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]

Facility

$0.18

Service Code	NDC 9999-9966-27
Hospital Charge Code	1719203
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]

Facility

$0.18

Service Code	NDC 9999-9966-27
Hospital Charge Code	1719203
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]

Facility

$0.09

Service Code	NDC 64679-604-16
Hospital Charge Code	1715906
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]

Facility

$0.09

Service Code	NDC 64679-604-16
Hospital Charge Code	1715906
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

PROPAFENONE 150 MG TABLET [11146]

Facility

$0.46

Service Code	NDC 0591-0582-01
Hospital Charge Code	1711536
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

PROPAFENONE 150 MG TABLET [11146]

Facility

$0.46

Service Code	NDC 0591-0582-01
Hospital Charge Code	1711536
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

PROPAFENONE 225 MG TABLET [11147]

Facility

$0.61

Service Code	NDC 0591-0583-01
Hospital Charge Code	1711953
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.46
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	$0.27
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	$0.46

PROPAFENONE 225 MG TABLET [11147]

Facility

$1.25

Service Code	NDC 53489-552-01
Hospital Charge Code	1711953
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.75
Rate for Payer: Aetna of CA Government/Medicare	$0.75
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94

PROPAFENONE 225 MG TABLET [11147]

Facility

$1.25

Service Code	NDC 53489-552-01
Hospital Charge Code	1711953
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$1.00
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94

PROPAFENONE 225 MG TABLET [11147]

Facility

$0.61

Service Code	NDC 0591-0583-01
Hospital Charge Code	1711953
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.49
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	$0.46

PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]

Facility

$0.98

Service Code	NDC 69680-130-60
Hospital Charge Code	1710957
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.44
Rate for Payer: Cigna of CA HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.74

PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]

Facility

$9.71

Service Code	NDC 60687-185-32
Hospital Charge Code	1710957
Hospital Revenue Code	259
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$7.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.83
Rate for Payer: Aetna of CA Government/Medicare	$5.83
Rate for Payer: Cash Price	$4.37
Rate for Payer: Health Smart Auto/Commercial	$5.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.83
Rate for Payer: LLUH Dept of Risk Management WC	$5.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.28

PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]

Facility

$9.71

Service Code	NDC 60687-185-33
Hospital Charge Code	1710957
Hospital Revenue Code	259
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$7.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.83
Rate for Payer: Aetna of CA Government/Medicare	$5.83
Rate for Payer: Cash Price	$4.37
Rate for Payer: Health Smart Auto/Commercial	$5.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.83
Rate for Payer: LLUH Dept of Risk Management WC	$5.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.28

PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]

Facility

$9.71

Service Code	NDC 60687-185-33
Hospital Charge Code	1710957
Hospital Revenue Code	259
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$7.77
Rate for Payer: Cash Price	$4.37
Rate for Payer: Cigna of CA HMO/PPO	$7.77
Rate for Payer: Health Smart Auto/Commercial	$5.83
Rate for Payer: LLUH Dept of Risk Management WC	$5.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.28

PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]

Facility

$0.60

Service Code	NDC 64380-184-01
Hospital Charge Code	1710957
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

Know your out-of-pocket cost for care.

All Charges