Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$0.97

Service Code	NDC 0832101500
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.73

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$0.97

Service Code	NDC 6838251201
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.73

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$0.48

Service Code	NDC 4254349301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$2.18

Service Code	NDC 6068742211
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.74
Rate for Payer: Cash Price	$0.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.74
Rate for Payer: Health Smart Auto/Commercial	$1.31
Rate for Payer: LLUH Dept of Risk Management WC	$1.20
Rate for Payer: Multiplan Commercial	$1.64

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$2.18

Service Code	NDC 6068742211
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.31
Rate for Payer: Aetna of CA Government/Medicare	$1.31
Rate for Payer: Cash Price	$0.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.74
Rate for Payer: Health Smart Auto/Commercial	$1.31
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.31
Rate for Payer: LLUH Dept of Risk Management WC	$1.20
Rate for Payer: Multiplan Commercial	$1.64

AMANTADINE HCL 100 MG CAPSULE [364]

Facility

$0.48

Service Code	NDC 6233224631
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]

Facility

$0.07

Service Code	NDC 0121064616
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]

Facility

$0.50

Service Code	NDC 6068779742
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
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	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]

Facility

$0.07

Service Code	NDC 0121064616
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]

Facility

$0.50

Service Code	NDC 6068779756
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.38

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]

Facility

$0.50

Service Code	NDC 6068779742
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.38

AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [365]

Facility

$0.50

Service Code	NDC 6068779756
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
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	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

AMBRISENTAN 10 MG TABLET [82308]

Facility

$46.08

Service Code	NDC 0378427193
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$20.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.86
Rate for Payer: Health Smart Auto/Commercial	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Commercial	$34.56

AMBRISENTAN 10 MG TABLET [82308]

Facility

$46.08

Service Code	NDC 4733523783
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$20.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.86
Rate for Payer: Health Smart Auto/Commercial	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Commercial	$34.56

AMBRISENTAN 10 MG TABLET [82308]

Facility

$46.08

Service Code	NDC 0378427193
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.65
Rate for Payer: Aetna of CA Government/Medicare	$27.65
Rate for Payer: Cash Price	$20.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.86
Rate for Payer: Health Smart Auto/Commercial	$27.65
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Commercial	$34.56

AMBRISENTAN 10 MG TABLET [82308]

Facility

$4.20

Service Code	NDC 5965149530
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

AMBRISENTAN 10 MG TABLET [82308]

Facility

$46.08

Service Code	NDC 4733523783
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.65
Rate for Payer: Aetna of CA Government/Medicare	$27.65
Rate for Payer: Cash Price	$20.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.86
Rate for Payer: Health Smart Auto/Commercial	$27.65
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Commercial	$34.56

AMBRISENTAN 10 MG TABLET [82308]

Facility

$4.20

Service Code	NDC 5965149530
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

AMBRISENTAN 5 MG TABLET [82307]

Facility

$582.30

Service Code	NDC 6195808011
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$320.26
Max. Negotiated Rate	$465.84
Rate for Payer: Cash Price	$262.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$465.84
Rate for Payer: Health Smart Auto/Commercial	$349.38
Rate for Payer: LLUH Dept of Risk Management WC	$320.26
Rate for Payer: Multiplan Commercial	$436.73

AMBRISENTAN 5 MG TABLET [82307]

Facility

$582.30

Service Code	NDC 6195808015
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$320.26
Max. Negotiated Rate	$465.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$349.38
Rate for Payer: Aetna of CA Government/Medicare	$349.38
Rate for Payer: Cash Price	$262.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$465.84
Rate for Payer: Health Smart Auto/Commercial	$349.38
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$349.38
Rate for Payer: LLUH Dept of Risk Management WC	$320.26
Rate for Payer: Multiplan Commercial	$436.73

AMBRISENTAN 5 MG TABLET [82307]

Facility

$46.08

Service Code	NDC 4733523683
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.65
Rate for Payer: Aetna of CA Government/Medicare	$27.65
Rate for Payer: Cash Price	$20.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.86
Rate for Payer: Health Smart Auto/Commercial	$27.65
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Commercial	$34.56

AMBRISENTAN 5 MG TABLET [82307]

Facility

$4.20

Service Code	NDC 5965149430
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

AMBRISENTAN 5 MG TABLET [82307]

Facility

$46.08

Service Code	NDC 4733523683
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$20.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.86
Rate for Payer: Health Smart Auto/Commercial	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Commercial	$34.56

AMBRISENTAN 5 MG TABLET [82307]

Facility

$582.30

Service Code	NDC 6195808011
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$320.26
Max. Negotiated Rate	$465.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$349.38
Rate for Payer: Aetna of CA Government/Medicare	$349.38
Rate for Payer: Cash Price	$262.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$465.84
Rate for Payer: Health Smart Auto/Commercial	$349.38
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$349.38
Rate for Payer: LLUH Dept of Risk Management WC	$320.26
Rate for Payer: Multiplan Commercial	$436.73

AMBRISENTAN 5 MG TABLET [82307]

Facility

$582.30

Service Code	NDC 6195808015
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$320.26
Max. Negotiated Rate	$465.84
Rate for Payer: Cash Price	$262.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$465.84
Rate for Payer: Health Smart Auto/Commercial	$349.38
Rate for Payer: LLUH Dept of Risk Management WC	$320.26
Rate for Payer: Multiplan Commercial	$436.73

Know your out-of-pocket cost for care.

All Charges