Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$2.90

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$2.32
Rate for Payer: Cash Price	$1.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.59
Rate for Payer: Multiplan Commercial	$2.17

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

Facility

$2.90

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$2.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.74
Rate for Payer: Aetna of CA Government/Medicare	$1.74
Rate for Payer: Cash Price	$1.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.59
Rate for Payer: Multiplan Commercial	$2.17

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

Facility

$2.90

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$2.32
Rate for Payer: Cash Price	$1.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.59
Rate for Payer: Multiplan Commercial	$2.17

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

Facility

$2.90

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$2.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.74
Rate for Payer: Aetna of CA Government/Medicare	$1.74
Rate for Payer: Cash Price	$1.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.59
Rate for Payer: Multiplan Commercial	$2.17

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

Facility

$0.93

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.70

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

Facility

$0.93

Service Code	HCPCS J0280
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.70

AMINOPHYLLINE ORAL SOLUTION (IV FORM) 25 MG/ML [4080417]

Facility

$0.10

Service Code	NDC 9994080417
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

AMINOPHYLLINE ORAL SOLUTION (IV FORM) 25 MG/ML [4080417]

Facility

$0.10

Service Code	NDC 9994080417
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

AMIODARONE 150 MG/3 ML VIAL - CODE [4080561]

Facility

$0.80

Service Code	HCPCS J0282
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.06
Rate for Payer: Aetna of CA Government/Medicare	$1.06
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.06
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: Multiplan Commercial	$1.32
Rate for Payer: Multiplan Commercial	$0.60

AMIODARONE 150 MG/3 ML VIAL - CODE [4080561]

Facility

$1.76

Service Code	HCPCS J0282
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.41
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: Multiplan Commercial	$0.60
Rate for Payer: Multiplan Commercial	$1.32

AMIODARONE 200 MG TABLET [9066]

Facility

$0.26

Service Code	NDC 6373905110
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

AMIODARONE 200 MG TABLET [9066]

Facility

$0.45

Service Code	NDC 0245014701
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

AMIODARONE 200 MG TABLET [9066]

Facility

$0.32

Service Code	NDC 6838222714
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

AMIODARONE 200 MG TABLET [9066]

Facility

$0.50

Service Code	NDC 6068743711
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.45

Service Code	NDC 0245014701
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

AMIODARONE 200 MG TABLET [9066]

Facility

$0.50

Service Code	NDC 6068743701
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.32

Service Code	NDC 6586273260
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

AMIODARONE 200 MG TABLET [9066]

Facility

$0.32

Service Code	NDC 6586273260
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 0245014789
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.33

AMIODARONE 200 MG TABLET [9066]

Facility

$0.32

Service Code	NDC 6838222714
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

AMIODARONE 200 MG TABLET [9066]

Facility

$0.26

Service Code	NDC 6373905110
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

AMIODARONE 200 MG TABLET [9066]

Facility

$0.50

Service Code	NDC 6068743711
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 0245014789
Hospital Charge Code	901700029
Hospital Revenue Code	259
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 Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

AMIODARONE 200 MG TABLET [9066]

Facility

$0.50

Service Code	NDC 6068743701
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.24

Service Code	NDC 7288803960
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

Know your out-of-pocket cost for care.

All Charges