Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]

Facility

$22.87

Service Code	CPT J3415
Hospital Charge Code	1720634
Hospital Revenue Code	636
Min. Negotiated Rate	$12.58
Max. Negotiated Rate	$17.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.72
Rate for Payer: Aetna of CA Government/Medicare	$13.72
Rate for Payer: Cash Price	$10.29
Rate for Payer: Health Smart Auto/Commercial	$13.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.72
Rate for Payer: LLUH Dept of Risk Management WC	$12.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.15

PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION [6744]

Facility

$22.87

Service Code	CPT J3415
Hospital Charge Code	1720634
Hospital Revenue Code	636
Min. Negotiated Rate	$12.58
Max. Negotiated Rate	$18.30
Rate for Payer: Cash Price	$10.29
Rate for Payer: Cigna of CA HMO/PPO	$18.30
Rate for Payer: Health Smart Auto/Commercial	$13.72
Rate for Payer: LLUH Dept of Risk Management WC	$12.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.15

PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]

Facility

$0.03

Service Code	NDC 8770140730
Hospital Charge Code	1711339
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PYRIDOXINE (VITAMIN B6) 100 MG TABLET [6745]

Facility

$0.03

Service Code	NDC 8770140730
Hospital Charge Code	1711339
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]

Facility

$0.03

Service Code	NDC 536440601
Hospital Charge Code	ERX6746
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PYRIDOXINE (VITAMIN B6) 25 MG TABLET [6746]

Facility

$0.03

Service Code	NDC 536440601
Hospital Charge Code	ERX6746
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885811
Hospital Charge Code	1710834
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

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885815
Hospital Charge Code	1710834
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.02

Service Code	NDC 5789685301
Hospital Charge Code	1710834
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
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	$0.02

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885811
Hospital Charge Code	1710834
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.02

Service Code	NDC 5789685301
Hospital Charge Code	1710834
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
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: Cash Price	$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	$0.02

PYRIDOXINE (VITAMIN B6) 50 MG TABLET [6748]

Facility

$0.28

Service Code	NDC 5026885815
Hospital Charge Code	1710834
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

PYRIDOXINE (VITAMIN B6) ORAL SOLUTION COMPOUND 1 MG/ML [4081140]

Facility

$19.88

Service Code	NDC 9994-0811-40
Hospital Charge Code	NDC4081140
Hospital Revenue Code	259
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$15.90
Rate for Payer: Cash Price	$8.95
Rate for Payer: Cigna of CA HMO/PPO	$15.90
Rate for Payer: Health Smart Auto/Commercial	$11.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.91

PYRIDOXINE (VITAMIN B6) ORAL SOLUTION COMPOUND 1 MG/ML [4081140]

Facility

$19.88

Service Code	NDC 9994-0811-40
Hospital Charge Code	NDC4081140
Hospital Revenue Code	259
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$14.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.93
Rate for Payer: Aetna of CA Government/Medicare	$11.93
Rate for Payer: Cash Price	$8.95
Rate for Payer: Health Smart Auto/Commercial	$11.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.91

PYRIMETHAMINE 25 MG TABLET [11246]

Facility

$900.00

Service Code	NDC 52054-330-95
Hospital Charge Code	1710061
Hospital Revenue Code	259
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$540.00
Rate for Payer: Aetna of CA Government/Medicare	$540.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Health Smart Auto/Commercial	$540.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$540.00
Rate for Payer: LLUH Dept of Risk Management WC	$495.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$675.00

PYRIMETHAMINE 25 MG TABLET [11246]

Facility

$900.00

Service Code	NDC 69413-330-30
Hospital Charge Code	1710061
Hospital Revenue Code	259
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$540.00
Rate for Payer: Aetna of CA Government/Medicare	$540.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Health Smart Auto/Commercial	$540.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$540.00
Rate for Payer: LLUH Dept of Risk Management WC	$495.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$675.00

PYRIMETHAMINE 25 MG TABLET [11246]

Facility

$900.00

Service Code	NDC 52054-330-95
Hospital Charge Code	1710061
Hospital Revenue Code	259
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$720.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cigna of CA HMO/PPO	$720.00
Rate for Payer: Health Smart Auto/Commercial	$540.00
Rate for Payer: LLUH Dept of Risk Management WC	$495.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$675.00

PYRIMETHAMINE 25 MG TABLET [11246]

Facility

$900.00

Service Code	NDC 69413-330-30
Hospital Charge Code	1710061
Hospital Revenue Code	259
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$720.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cigna of CA HMO/PPO	$720.00
Rate for Payer: Health Smart Auto/Commercial	$540.00
Rate for Payer: LLUH Dept of Risk Management WC	$495.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$675.00

PYRIMETHAMINE ORAL SOLUTION COMPOUND 2 MG/ML [4080328]

Facility

$0.09

Service Code	NDC 9994-0803-28
Hospital Charge Code	1715993
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

PYRIMETHAMINE ORAL SOLUTION COMPOUND 2 MG/ML [4080328]

Facility

$0.09

Service Code	NDC 9994-0803-28
Hospital Charge Code	1715993
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

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.38

Service Code	NDC 47335-904-88
Hospital Charge Code	1713146
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.64

Service Code	NDC 60687-349-01
Hospital Charge Code	1713146
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.38

Service Code	NDC 47335-904-88
Hospital Charge Code	1713146
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.56

Service Code	NDC 0904-6640-61
Hospital Charge Code	1713146
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.42

QUETIAPINE 100 MG TABLET [21824]

Facility

$0.64

Service Code	NDC 60687-349-11
Hospital Charge Code	1713146
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

Know your out-of-pocket cost for care.

All Charges