Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 60687-437-11
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

$0.44

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

$0.44

Service Code	NDC 68084-371-01
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	$0.36
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.34

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

AMIODARONE 200 MG TABLET [9066]

Facility

$0.44

Service Code	NDC 60687-437-01
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

$0.33

Service Code	NDC 0245-0147-60
Hospital Charge Code	1712089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.25

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	$0.24
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: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.44

Service Code	NDC 68084-371-11
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

$0.32

Service Code	NDC 65862-732-60
Hospital Charge Code	1712089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
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: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.45

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 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$0.70

Service Code	CPT J0282
Hospital Charge Code	1759831
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Cigna of CA HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.48
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: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$0.94

Service Code	CPT J0282
Hospital Charge Code	1720997
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cash Price	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$0.91

Service Code	CPT J0282
Hospital Charge Code	1721120
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$0.94

Service Code	CPT J0282
Hospital Charge Code	1720997
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$0.91

Service Code	CPT J0282
Hospital Charge Code	1721120
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]

Facility

$0.80

Service Code	CPT J0282
Hospital Charge Code	1759831
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.48
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	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
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: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

AMIODARONE ORAL SUSPENSION COMPOUND 5 MG/ML [4080238]

Facility

$0.32

Service Code	NDC 9994-0802-38
Hospital Charge Code	1715952
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
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: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

AMIODARONE ORAL SUSPENSION COMPOUND 5 MG/ML [4080238]

Facility

$0.32

Service Code	NDC 9994-0802-38
Hospital Charge Code	1715952
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

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$1.37

Service Code	NDC 51079-563-01
Hospital Charge Code	1711133
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.03
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: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.03

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$1.37

Service Code	NDC 51079-563-01
Hospital Charge Code	1711133
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.03

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$0.36

Service Code	NDC 16729-175-01
Hospital Charge Code	1711133
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
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: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

AMITRIPTYLINE 100 MG TABLET [433]

Facility

$0.36

Service Code	NDC 16729-175-01
Hospital Charge Code	1711133
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.27

Know your out-of-pocket cost for care.

All Charges