Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$14.00

Service Code	NDC 70377-102-11
Hospital Charge Code	1710315
Hospital Revenue Code	259
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$10.50
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	$6.30
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 Beech St/Commercial/PHCS	$10.50

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$13.00

Service Code	NDC 72205-049-30
Hospital Charge Code	1710315
Hospital Revenue Code	259
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$9.75

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$13.00

Service Code	NDC 72205-049-30
Hospital Charge Code	1710315
Hospital Revenue Code	259
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$9.75
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	$5.85
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 Beech St/Commercial/PHCS	$9.75

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$7.16

Service Code	NDC 69680-115-30
Hospital Charge Code	1710315
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.73
Rate for Payer: Cash Price	$3.22
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$5.37

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$14.00

Service Code	NDC 70377-102-11
Hospital Charge Code	1710315
Hospital Revenue Code	259
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.20
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$10.50

AMINOCAPROIC ACID 500 MG TABLET [9063]

Facility

$7.16

Service Code	NDC 69680-115-30
Hospital Charge Code	1710315
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.37
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	$3.22
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 Beech St/Commercial/PHCS	$5.37

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]

Facility

$1.72

Service Code	CPT J0280
Hospital Charge Code	1720024
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.77
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]

Facility

$1.72

Service Code	CPT J0280
Hospital Charge Code	1720024
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

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

Facility

$1.72

Service Code	CPT J0280
Hospital Charge Code	1720024
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.77
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

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

Facility

$1.72

Service Code	CPT J0280
Hospital Charge Code	1720024
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

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

Facility

$1.72

Service Code	CPT J0280
Hospital Charge Code	1720024
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.77
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

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

Facility

$1.72

Service Code	CPT J0280
Hospital Charge Code	1720024
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

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

Facility

$0.55

Service Code	CPT J0280
Hospital Charge Code	1757205
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

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

Facility

$0.55

Service Code	CPT J0280
Hospital Charge Code	1757205
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

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

Facility

$0.10

Service Code	NDC 9994-0804-17
Hospital Charge Code	1715059
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: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

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

Facility

$0.10

Service Code	NDC 9994-0804-17
Hospital Charge Code	1715059
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

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

Facility

$0.70

Service Code	CPT J0282
Hospital Charge Code	1759831
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

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

Facility

$1.39

Service Code	CPT J0282
Hospital Charge Code	1759831
Hospital Revenue Code	636
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 0245-0147-89
Hospital Charge Code	1712089
Hospital Revenue Code	259
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 68084-371-11
Hospital Charge Code	1712089
Hospital Revenue Code	259
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.45

Service Code	NDC 0245-0147-01
Hospital Charge Code	1712089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.34
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: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

AMIODARONE 200 MG TABLET [9066]

Facility

$0.24

Service Code	NDC 72888-039-60
Hospital Charge Code	1712089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

AMIODARONE 200 MG TABLET [9066]

Facility

$0.32

Service Code	NDC 68382-227-14
Hospital Charge Code	1712089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.24

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 0245-0147-89
Hospital Charge Code	1712089
Hospital Revenue Code	259
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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.33

Service Code	NDC 0245-0147-60
Hospital Charge Code	1712089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

Know your out-of-pocket cost for care.

All Charges