Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.60

Service Code	NDC 64380-184-01
Hospital Charge Code	1710957
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

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	$7.77
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 325 MG CAPSULE,EXTENDED RELEASE 12 HR [37644]

Facility

$8.89

Service Code	NDC 49884-210-02
Hospital Charge Code	1710994
Hospital Revenue Code	259
Min. Negotiated Rate	$4.89
Max. Negotiated Rate	$6.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.33
Rate for Payer: Aetna of CA Government/Medicare	$5.33
Rate for Payer: Cash Price	$4.00
Rate for Payer: Health Smart Auto/Commercial	$5.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.33
Rate for Payer: LLUH Dept of Risk Management WC	$4.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.67

PROPAFENONE ER 325 MG CAPSULE,EXTENDED RELEASE 12 HR [37644]

Facility

$8.89

Service Code	NDC 49884-210-02
Hospital Charge Code	1710994
Hospital Revenue Code	259
Min. Negotiated Rate	$4.89
Max. Negotiated Rate	$7.11
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of CA HMO/PPO	$7.11
Rate for Payer: Health Smart Auto/Commercial	$5.33
Rate for Payer: LLUH Dept of Risk Management WC	$4.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.67

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$3.05

Service Code	NDC 0998-0016-15
Hospital Charge Code	1740258
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.44
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cigna of CA HMO/PPO	$2.44
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.29

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$2.81

Service Code	NDC 24208-730-06
Hospital Charge Code	1740258
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Cash Price	$1.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.11

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$2.81

Service Code	NDC 61314-016-01
Hospital Charge Code	1740258
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.25
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cigna of CA HMO/PPO	$2.25
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.11

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$3.05

Service Code	NDC 0998-0016-15
Hospital Charge Code	1740258
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.83
Rate for Payer: Aetna of CA Government/Medicare	$1.83
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.29

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$2.81

Service Code	NDC 24208-730-06
Hospital Charge Code	1740258
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.25
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cigna of CA HMO/PPO	$2.25
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.11

PROPARACAINE 0.5 % EYE DROPS [6644]

Facility

$2.81

Service Code	NDC 61314-016-01
Hospital Charge Code	1740258
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.11
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Cash Price	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.11

PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]

Facility

$0.36

Service Code	CPT J2704
Hospital Charge Code	1720895
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]

Facility

$0.26

Service Code	CPT J2704
Hospital Charge Code	1720893
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]

Facility

$0.14

Service Code	CPT J2704
Hospital Charge Code	NDG11150
Hospital Revenue Code	636
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	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]

Facility

$0.26

Service Code	CPT J2704
Hospital Charge Code	1720893
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]

Facility

$0.36

Service Code	CPT J2704
Hospital Charge Code	NDG11150
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]

Facility

$0.35

Service Code	CPT J2704
Hospital Charge Code	1720895
Hospital Revenue Code	636
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPOFOL 200 MG/20 ML INTRAVENOUS EMULSION- CODE [408011150]

Facility

$0.36

Service Code	CPT J2704
Hospital Charge Code	1720893
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPOFOL 200 MG/20 ML INTRAVENOUS EMULSION- CODE [408011150]

Facility

$0.36

Service Code	CPT J2704
Hospital Charge Code	1720893
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPOFOL INFUSION 10 MG/ML CONTINUOUS [40840026]

Facility

$0.36

Service Code	CPT J2704
Hospital Charge Code	1720895
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPOFOL INFUSION 10 MG/ML CONTINUOUS [40840026]

Facility

$0.36

Service Code	CPT J2704
Hospital Charge Code	1720895
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

PROPRANOLOL 10 MG TABLET [6656]

Facility

$0.30

Service Code	NDC 60687-587-11
Hospital Charge Code	1710283
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PROPRANOLOL 10 MG TABLET [6656]

Facility

$0.30

Service Code	NDC 60687-587-11
Hospital Charge Code	1710283
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PROPRANOLOL 10 MG TABLET [6656]

Facility

$0.30

Service Code	NDC 60687-587-01
Hospital Charge Code	1710283
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

PROPRANOLOL 10 MG TABLET [6656]

Facility

$0.28

Service Code	NDC 0904-6550-61
Hospital Charge Code	1710283
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

Know your out-of-pocket cost for care.

All Charges