Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$0.07

Service Code	NDC 0121-0646-16
Hospital Charge Code	1715916
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

AMBRISENTAN 10 MG TABLET [82308]

Facility

$450.38

Service Code	NDC 61958-0802-1
Hospital Charge Code	1712539
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$360.30
Rate for Payer: Cash Price	$202.67
Rate for Payer: Cigna of CA HMO/PPO	$360.30
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 10 MG TABLET [82308]

Facility

$450.38

Service Code	NDC 61958-0802-1
Hospital Charge Code	1712539
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$337.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.23
Rate for Payer: Aetna of CA Government/Medicare	$270.23
Rate for Payer: Cash Price	$202.67
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 10 MG TABLET [82308]

Facility

$46.08

Service Code	NDC 47335-237-83
Hospital Charge Code	1712539
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$20.74
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$34.56

AMBRISENTAN 10 MG TABLET [82308]

Facility

$46.08

Service Code	NDC 47335-237-83
Hospital Charge Code	1712539
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$34.56
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: Health Smart Auto/Commercial	$27.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.56

AMBRISENTAN 10 MG TABLET [82308]

Facility

$450.38

Service Code	NDC 61958-0802-5
Hospital Charge Code	1712539
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$337.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.23
Rate for Payer: Aetna of CA Government/Medicare	$270.23
Rate for Payer: Cash Price	$202.67
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 10 MG TABLET [82308]

Facility

$450.38

Service Code	NDC 61958-0802-5
Hospital Charge Code	1712539
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$360.30
Rate for Payer: Cash Price	$202.67
Rate for Payer: Cigna of CA HMO/PPO	$360.30
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 5 MG TABLET [82307]

Facility

$450.38

Service Code	NDC 61958-0801-5
Hospital Charge Code	ERX82307
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$360.30
Rate for Payer: Cash Price	$202.67
Rate for Payer: Cigna of CA HMO/PPO	$360.30
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 5 MG TABLET [82307]

Facility

$46.08

Service Code	NDC 47335-236-83
Hospital Charge Code	ERX82307
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$20.74
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$34.56

AMBRISENTAN 5 MG TABLET [82307]

Facility

$450.38

Service Code	NDC 61958-0801-1
Hospital Charge Code	ERX82307
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$360.30
Rate for Payer: Cash Price	$202.67
Rate for Payer: Cigna of CA HMO/PPO	$360.30
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 5 MG TABLET [82307]

Facility

$46.08

Service Code	NDC 47335-236-83
Hospital Charge Code	ERX82307
Hospital Revenue Code	259
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$34.56
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: Health Smart Auto/Commercial	$27.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.65
Rate for Payer: LLUH Dept of Risk Management WC	$25.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.56

AMBRISENTAN 5 MG TABLET [82307]

Facility

$450.38

Service Code	NDC 61958-0801-5
Hospital Charge Code	ERX82307
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$337.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.23
Rate for Payer: Aetna of CA Government/Medicare	$270.23
Rate for Payer: Cash Price	$202.67
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMBRISENTAN 5 MG TABLET [82307]

Facility

$450.38

Service Code	NDC 61958-0801-1
Hospital Charge Code	ERX82307
Hospital Revenue Code	259
Min. Negotiated Rate	$247.71
Max. Negotiated Rate	$337.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.23
Rate for Payer: Aetna of CA Government/Medicare	$270.23
Rate for Payer: Cash Price	$202.67
Rate for Payer: Health Smart Auto/Commercial	$270.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.23
Rate for Payer: LLUH Dept of Risk Management WC	$247.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.78

AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]

Facility

$2.19

Service Code	CPT J0278
Hospital Charge Code	1752069
Hospital Revenue Code	636
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$4.41
Rate for Payer: Aetna of CA Government/Medicare	$1.31
Rate for Payer: Aetna of CA Government/Medicare	$4.19
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.79
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cash Price	$3.31
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Smart Auto/Commercial	$4.41
Rate for Payer: Health Smart Auto/Commercial	$1.31
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$4.19
Rate for Payer: Health Smart Auto/Commercial	$2.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$2.56
Rate for Payer: LLUH Dept of Risk Management WC	$3.84
Rate for Payer: LLUH Dept of Risk Management WC	$4.04
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.64

AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]

Facility

$7.35

Service Code	CPT J0278
Hospital Charge Code	1752069
Hospital Revenue Code	636
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$5.88
Rate for Payer: Cash Price	$3.31
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cigna of CA HMO/PPO	$5.88
Rate for Payer: Cigna of CA HMO/PPO	$5.59
Rate for Payer: Cigna of CA HMO/PPO	$3.72
Rate for Payer: Cigna of CA HMO/PPO	$3.84
Rate for Payer: Cigna of CA HMO/PPO	$1.75
Rate for Payer: Health Smart Auto/Commercial	$4.19
Rate for Payer: Health Smart Auto/Commercial	$2.79
Rate for Payer: Health Smart Auto/Commercial	$4.41
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$1.31
Rate for Payer: LLUH Dept of Risk Management WC	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.84
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$4.04
Rate for Payer: LLUH Dept of Risk Management WC	$2.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.64

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]

Facility

$7.35

Service Code	CPT J0278
Hospital Charge Code	1720006
Hospital Revenue Code	636
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$5.88
Rate for Payer: Cash Price	$3.31
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cigna of CA HMO/PPO	$3.84
Rate for Payer: Cigna of CA HMO/PPO	$5.88
Rate for Payer: Cigna of CA HMO/PPO	$3.72
Rate for Payer: Health Smart Auto/Commercial	$2.79
Rate for Payer: Health Smart Auto/Commercial	$4.41
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.56
Rate for Payer: LLUH Dept of Risk Management WC	$4.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]

Facility

$4.80

Service Code	CPT J0278
Hospital Charge Code	1720006
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.79
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.79
Rate for Payer: Aetna of CA Government/Medicare	$4.41
Rate for Payer: Cash Price	$2.16
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$3.31
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$4.41
Rate for Payer: Health Smart Auto/Commercial	$2.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.41
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.56
Rate for Payer: LLUH Dept of Risk Management WC	$4.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.51

AMILORIDE 5 MG TABLET [391]

Facility

$0.27

Service Code	NDC 0574-0292-01
Hospital Charge Code	1710531
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

AMILORIDE 5 MG TABLET [391]

Facility

$0.27

Service Code	NDC 0574-0292-01
Hospital Charge Code	1710531
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
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	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

AMINO ACID INFUSION 7 % INTRAVENOUS SOLUTION [4089055]

Facility

$315.00

Service Code	NDC 9994-0890-55
Hospital Charge Code	NDC4089055
Hospital Revenue Code	250
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$236.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$189.00
Rate for Payer: Aetna of CA Government/Medicare	$189.00
Rate for Payer: Cash Price	$141.75
Rate for Payer: Health Smart Auto/Commercial	$189.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$189.00
Rate for Payer: LLUH Dept of Risk Management WC	$173.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$236.25

AMINO ACID INFUSION 7 % INTRAVENOUS SOLUTION [4089055]

Facility

$315.00

Service Code	NDC 9994-0890-55
Hospital Charge Code	NDC4089055
Hospital Revenue Code	250
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$252.00
Rate for Payer: Cash Price	$141.75
Rate for Payer: Cigna of CA HMO/PPO	$252.00
Rate for Payer: Health Smart Auto/Commercial	$189.00
Rate for Payer: LLUH Dept of Risk Management WC	$173.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$236.25

AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]

Facility

$14.18

Service Code	NDC 49411-052-08
Hospital Charge Code	NDG9062
Hospital Revenue Code	259
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$10.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.51
Rate for Payer: Aetna of CA Government/Medicare	$8.51
Rate for Payer: Cash Price	$6.38
Rate for Payer: Health Smart Auto/Commercial	$8.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.51
Rate for Payer: LLUH Dept of Risk Management WC	$7.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.64

AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]

Facility

$14.18

Service Code	NDC 49411-052-08
Hospital Charge Code	NDG9062
Hospital Revenue Code	259
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$11.34
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna of CA HMO/PPO	$11.34
Rate for Payer: Health Smart Auto/Commercial	$8.51
Rate for Payer: LLUH Dept of Risk Management WC	$7.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.64

AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]

Facility

$0.44

Service Code	CPT S0017
Hospital Charge Code	1720161
Hospital Revenue Code	636
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

AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]

Facility

$0.44

Service Code	CPT S0017
Hospital Charge Code	1720161
Hospital Revenue Code	636
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

Know your out-of-pocket cost for care.

All Charges