Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]

Facility

$4.80

Service Code	HCPCS J0278
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cash Price	$2.48
Rate for Payer: Cash Price	$2.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.70
Rate for Payer: Health Smart Auto/Commercial	$2.79
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	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.56
Rate for Payer: Multiplan Commercial	$3.38
Rate for Payer: Multiplan Commercial	$3.49
Rate for Payer: Multiplan Commercial	$3.60

AMILORIDE 5 MG TABLET [391]

Facility

$0.27

Service Code	NDC 0574-0292-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

AMILORIDE 5 MG TABLET [391]

Facility

$0.27

Service Code	NDC 0574-0292-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
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	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
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 Commercial	$0.20

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

Facility

$1.15

Service Code	NDC 31722-035-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.69
Rate for Payer: Aetna of CA Government/Medicare	$0.69
Rate for Payer: Cash Price	$0.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.86

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

Facility

$1.15

Service Code	NDC 31722-035-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.92
Rate for Payer: Cash Price	$0.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.86

AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]

Facility

$0.62

Service Code	HCPCS J0281
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Commercial	$0.47

AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]

Facility

$0.44

Service Code	HCPCS J0281
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Multiplan Commercial	$0.33

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$28.70

Service Code	NDC 60687-739-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$22.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.22
Rate for Payer: Aetna of CA Government/Medicare	$17.22
Rate for Payer: Cash Price	$15.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.96
Rate for Payer: Health Smart Auto/Commercial	$17.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.22
Rate for Payer: LLUH Dept of Risk Management WC	$15.79
Rate for Payer: Multiplan Commercial	$21.52

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$13.00

Service Code	NDC 72205-049-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$7.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$7.16

Service Code	NDC 69680-115-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.30
Rate for Payer: Aetna of CA Government/Medicare	$4.30
Rate for Payer: Cash Price	$3.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.73
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Commercial	$5.37

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$28.70

Service Code	NDC 60687-739-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$22.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.22
Rate for Payer: Aetna of CA Government/Medicare	$17.22
Rate for Payer: Cash Price	$15.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.96
Rate for Payer: Health Smart Auto/Commercial	$17.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.22
Rate for Payer: LLUH Dept of Risk Management WC	$15.79
Rate for Payer: Multiplan Commercial	$21.52

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$13.00

Service Code	NDC 72205-049-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$7.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$14.00

Service Code	NDC 70377-102-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.40
Rate for Payer: Aetna of CA Government/Medicare	$8.40
Rate for Payer: Cash Price	$7.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.20
Rate for Payer: Health Smart Auto/Commercial	$8.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.40
Rate for Payer: LLUH Dept of Risk Management WC	$7.70
Rate for Payer: Multiplan Commercial	$10.50

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$28.70

Service Code	NDC 60687-739-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$22.96
Rate for Payer: Cash Price	$15.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.96
Rate for Payer: Health Smart Auto/Commercial	$17.22
Rate for Payer: LLUH Dept of Risk Management WC	$15.79
Rate for Payer: Multiplan Commercial	$21.52

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$7.16

Service Code	NDC 69680-115-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.73
Rate for Payer: Cash Price	$3.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.73
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Commercial	$5.37

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$28.70

Service Code	NDC 60687-739-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$22.96
Rate for Payer: Cash Price	$15.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.96
Rate for Payer: Health Smart Auto/Commercial	$17.22
Rate for Payer: LLUH Dept of Risk Management WC	$15.79
Rate for Payer: Multiplan Commercial	$21.52

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$14.00

Service Code	NDC 70377-102-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.20
Rate for Payer: Cash Price	$7.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.20
Rate for Payer: Health Smart Auto/Commercial	$8.40
Rate for Payer: LLUH Dept of Risk Management WC	$7.70
Rate for Payer: Multiplan Commercial	$10.50

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]

Facility

$2.40

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]

Facility

$2.40

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION CDL ONLY [4084072]

Facility

$2.40

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION CDL ONLY [4084072]

Facility

$2.40

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION (RAD) [4084071]

Facility

$2.40

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION (RAD) [4084071]

Facility

$2.40

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION CDL ONLY [408407]

Facility

$0.77

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Commercial	$0.58

AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION CDL ONLY [408407]

Facility

$0.77

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Cash Price	$0.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Commercial	$0.58

Know your out-of-pocket cost for care.

All Charges