Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

EZETIMIBE 10 MG TABLET [34153]

Facility

$0.37

Service Code	NDC 67877-490-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
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	$0.28

EZETIMIBE 10 MG TABLET [34153]

Facility

$0.34

Service Code	NDC 59651-052-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
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	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

EZETIMIBE 10 MG TABLET [34153]

Facility

$0.34

Service Code	NDC 59651-052-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

EZETIMIBE 10 MG TABLET [34153]

Facility

$0.35

Service Code	NDC 0781-5690-31
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

EZETIMIBE 10 MG TABLET [34153]

Facility

$0.35

Service Code	NDC 0781-5690-31
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

EZETIMIBE 10 MG TABLET [34153]

Facility

$0.37

Service Code	NDC 67877-490-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
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	$0.17
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	$0.28

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$1.40

Service Code	NDC 33342-026-07
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.05

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$1.40

Service Code	NDC 31722-708-30
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.05

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$2.75

Service Code	NDC 60687-103-95
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.65
Rate for Payer: Aetna of CA Government/Medicare	$1.65
Rate for Payer: Cash Price	$1.24
Rate for Payer: Health Smart Auto/Commercial	$1.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.06

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$1.40

Service Code	NDC 31722-708-30
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Cash Price	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.05

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$1.40

Service Code	NDC 33342-026-07
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Cash Price	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.05

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$2.75

Service Code	NDC 60687-103-25
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.20
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna of CA HMO/PPO	$2.20
Rate for Payer: Health Smart Auto/Commercial	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.06

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$2.75

Service Code	NDC 60687-103-25
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.65
Rate for Payer: Aetna of CA Government/Medicare	$1.65
Rate for Payer: Cash Price	$1.24
Rate for Payer: Health Smart Auto/Commercial	$1.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.06

FAMCICLOVIR 500 MG TABLET [13358]

Facility

$2.75

Service Code	NDC 60687-103-95
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.20
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna of CA HMO/PPO	$2.20
Rate for Payer: Health Smart Auto/Commercial	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.06

FAMOTIDINE 10 MG/ML INJECTION. [4081320]

Facility

$0.54

Service Code	CPT S0028
Hospital Charge Code	1768064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

FAMOTIDINE 10 MG/ML INJECTION. [4081320]

Facility

$0.54

Service Code	CPT S0028
Hospital Charge Code	1768064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION [10009]

Facility

$0.53

Service Code	CPT S0028
Hospital Charge Code	NDG10009B
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION [10009]

Facility

$0.53

Service Code	CPT S0028
Hospital Charge Code	NDG10009B
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION [10009]

Facility

$0.53

Service Code	CPT S0028
Hospital Charge Code	NDG10009A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION [10009]

Facility

$0.53

Service Code	CPT S0028
Hospital Charge Code	NDG10009A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.12

Service Code	NDC 87701-43268
Hospital Charge Code	1711967
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
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: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.14

Service Code	NDC 46122-394-65
Hospital Charge Code	1711967
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.09

Service Code	NDC 0904-5529-52
Hospital Charge Code	1711967
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: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.29

Service Code	NDC 0113-0141-65
Hospital Charge Code	1711967
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.22

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.09

Service Code	NDC 0904-5529-52
Hospital Charge Code	1711967
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.07

Know your out-of-pocket cost for care.

All Charges