Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.10

Service Code	NDC 46122-394-75
Hospital Charge Code	1711967
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

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.13

Service Code	NDC 8770142913
Hospital Charge Code	1711967
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

FAMOTIDINE 10 MG TABLET [15065]

Facility

$0.09

Service Code	NDC 55111-118-90
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

$0.09

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

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: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.36

Service Code	NDC 16837-872-30
Hospital Charge Code	1711967
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

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	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$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

$0.10

Service Code	NDC 46122-394-75
Hospital Charge Code	1711967
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

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

$0.13

Service Code	NDC 8770142913
Hospital Charge Code	1711967
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

FAMOTIDINE 20 MG TABLET [10011]

Facility

$0.09

Service Code	NDC 0904-7193-61
Hospital Charge Code	1712052
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 20 MG TABLET [10011]

Facility

$0.09

Service Code	NDC 0904-7193-61
Hospital Charge Code	1712052
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

FAMOTIDINE 20 MG TABLET [10011]

Facility

$0.17

Service Code	NDC 68001-397-00
Hospital Charge Code	1712052
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.13

FAMOTIDINE 20 MG TABLET [10011]

Facility

$0.17

Service Code	NDC 68001-397-00
Hospital Charge Code	1712052
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

$2.37

Service Code	NDC 68382-444-05
Hospital Charge Code	1715188
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.07
Rate for Payer: Cigna of CA HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.78

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

$2.38

Service Code	NDC 68180-150-01
Hospital Charge Code	1715188
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.43
Rate for Payer: Aetna of CA Government/Medicare	$1.43
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.78

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

$2.38

Service Code	NDC 68180-150-01
Hospital Charge Code	1715188
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.07
Rate for Payer: Cigna of CA HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.78

FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION [10010]

Facility

$2.37

Service Code	NDC 68382-444-05
Hospital Charge Code	1715188
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.42
Rate for Payer: Aetna of CA Government/Medicare	$1.42
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.78

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.35

Service Code	NDC 50268-304-15
Hospital Charge Code	1712055
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

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.35

Service Code	NDC 50268-304-11
Hospital Charge Code	1712055
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

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.34

Service Code	NDC 68001-398-00
Hospital Charge Code	1712055
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

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.34

Service Code	NDC 0172-5729-60
Hospital Charge Code	1712055
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

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.35

Service Code	NDC 50268-304-15
Hospital Charge Code	1712055
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

FAMOTIDINE 40 MG TABLET [10012]

Facility

$0.34

Service Code	NDC 0172-5729-60
Hospital Charge Code	1712055
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

Know your out-of-pocket cost for care.

All Charges