Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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 50 MG/ML INTRAVENOUS SOLUTION [93084]

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 EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
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: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$1.06
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
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	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$1.32
Rate for Payer: Multiplan Commercial	$0.89
Rate for Payer: Multiplan Commercial	$0.60
Rate for Payer: Multiplan Commercial	$0.86
Rate for Payer: Multiplan Commercial	$0.70

AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$1.19

Service Code	HCPCS J0282
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.86
Rate for Payer: Multiplan Commercial	$0.89
Rate for Payer: Multiplan Commercial	$0.60
Rate for Payer: Multiplan Commercial	$1.32
Rate for Payer: Multiplan Commercial	$0.70

AMIODARONE ORAL SUSPENSION COMPOUND 5 MG/ML [4080238]

Facility

$0.32

Service Code	NDC 9994080238
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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080238]

Facility

$0.32

Service Code	NDC 9994080238
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

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$0.36

Service Code	NDC 1672917501
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$1.37

Service Code	NDC 5107956301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$1.03

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$1.37

Service Code	NDC 5107956301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$1.03

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$0.36

Service Code	NDC 1672917501
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.09

Service Code	NDC 2930041901
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.50

Service Code	NDC 5026803715
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

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.50

Service Code	NDC 5026803715
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

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.50

Service Code	NDC 5026803711
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

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.17

Service Code	NDC 5766468788
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.09

Service Code	NDC 2930041901
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.50

Service Code	NDC 5026803711
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

AMITRIPTYLINE 10 MG TABLET [432]

Facility

$0.17

Service Code	NDC 5766468788
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

AMITRIPTYLINE 25 MG TABLET [435]

Facility

$0.11

Service Code	NDC 2930042001
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

AMITRIPTYLINE 25 MG TABLET [435]

Facility

$0.50

Service Code	NDC 5026803811
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

AMITRIPTYLINE 25 MG TABLET [435]

Facility

$0.50

Service Code	NDC 5026803815
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

AMITRIPTYLINE 25 MG TABLET [435]

Facility

$0.11

Service Code	NDC 2930042001
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

AMITRIPTYLINE 25 MG TABLET [435]

Facility

$0.50

Service Code	NDC 5026803815
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

AMITRIPTYLINE 25 MG TABLET [435]

Facility

$0.50

Service Code	NDC 5026803811
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

AMITRIPTYLINE 50 MG TABLET [436]

Facility

$0.70

Service Code	NDC 6068744401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

AMITRIPTYLINE 50 MG TABLET [436]

Facility

$0.69

Service Code	NDC 5766468988
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

Know your out-of-pocket cost for care.

All Charges