Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PROPYLENE GLYCOL 0.6 % EYE DROPS [106794]

Facility

$1.27

Service Code	NDC 0065-1433-02
Hospital Charge Code	NDG106794
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.57
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

PROPYLENE GLYCOL 0.6 % EYE DROPS [106794]

Facility

$1.27

Service Code	NDC 0065-1433-02
Hospital Charge Code	NDG106794
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

PROPYLTHIOURACIL 50 MG TABLET [6662]

Facility

$0.90

Service Code	NDC 67253-651-10
Hospital Charge Code	1711046
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

PROPYLTHIOURACIL 50 MG TABLET [6662]

Facility

$0.90

Service Code	NDC 0228-2348-10
Hospital Charge Code	1711046
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

PROPYLTHIOURACIL 50 MG TABLET [6662]

Facility

$0.90

Service Code	NDC 0228-2348-10
Hospital Charge Code	1711046
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

PROPYLTHIOURACIL 50 MG TABLET [6662]

Facility

$0.90

Service Code	NDC 67253-651-10
Hospital Charge Code	1711046
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

PROPYLTHIOURACIL ORAL SUSPENSION COMPOUND 5 MG/ML [4080325]

Facility

$0.90

Service Code	NDC 9994-0803-25
Hospital Charge Code	1715165
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

PROPYLTHIOURACIL ORAL SUSPENSION COMPOUND 5 MG/ML [4080325]

Facility

$0.90

Service Code	NDC 9994-0803-25
Hospital Charge Code	1715165
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$1.40

Service Code	CPT J2720
Hospital Charge Code	1720150
Hospital Revenue Code	636
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cigna of CA HMO/PPO	$1.12
Rate for Payer: Cigna of CA HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.05

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$2.09

Service Code	CPT J2720
Hospital Charge Code	1720140
Hospital Revenue Code	636
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$1.25
Rate for Payer: Cash Price	$0.94
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.79

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$1.40

Service Code	CPT J2720
Hospital Charge Code	1720150
Hospital Revenue Code	636
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.67

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION [6677]

Facility

$3.72

Service Code	CPT J2720
Hospital Charge Code	1720140
Hospital Revenue Code	636
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cash Price	$0.94
Rate for Payer: Cigna of CA HMO/PPO	$2.98
Rate for Payer: Cigna of CA HMO/PPO	$1.67
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: LLUH Dept of Risk Management WC	$1.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.79

PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID [111029]

Facility

$0.05

Service Code	NDC 50580-536-04
Hospital Charge Code	NDG111029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID [111029]

Facility

$0.05

Service Code	NDC 50580-536-04
Hospital Charge Code	NDG111029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

PSEUDOEPHEDRINE 60 MG TABLET [6715]

Facility

$0.07

Service Code	NDC 0904-6907-06
Hospital Charge Code	1710632
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

PSEUDOEPHEDRINE 60 MG TABLET [6715]

Facility

$0.07

Service Code	NDC 0904-6907-06
Hospital Charge Code	1710632
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

PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET [11218]

Facility

$0.44

Service Code	NDC 37000-024-04
Hospital Charge Code	1716011
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.33

PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET [11218]

Facility

$0.44

Service Code	NDC 37000-024-04
Hospital Charge Code	1716011
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.33

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-04
Hospital Charge Code	ERX205431
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-10
Hospital Charge Code	ERX205431
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-10
Hospital Charge Code	ERX205431
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]

Facility

$0.50

Service Code	NDC 37000-023-04
Hospital Charge Code	ERX205431
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$6.06

Service Code	NDC 61748-012-06
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$2.73
Rate for Payer: Cigna of CA HMO/PPO	$4.85
Rate for Payer: Health Smart Auto/Commercial	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.54

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$6.06

Service Code	NDC 61748-012-06
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$4.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.64
Rate for Payer: Aetna of CA Government/Medicare	$3.64
Rate for Payer: Cash Price	$2.73
Rate for Payer: Health Smart Auto/Commercial	$3.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.54

PYRAZINAMIDE 500 MG TABLET [6738]

Facility

$5.32

Service Code	NDC 33342-447-11
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$3.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.39
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.99

Know your out-of-pocket cost for care.

All Charges