Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMLODIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080240]

Facility

$0.04

Service Code	NDC 9994-0802-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

AMLODIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080240]

Facility

$0.04

Service Code	NDC 9994-0802-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION [439]

Facility

$0.41

Service Code	NDC 1678414012
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION [439]

Facility

$0.41

Service Code	NDC 1678414012
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

AMMONIUM CHLORIDE ORAL SOLUTION (IV FORM) 5 MEQ/ML [4080418]

Facility

$0.25

Service Code	NDC 9994-0804-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

AMMONIUM CHLORIDE ORAL SOLUTION (IV FORM) 5 MEQ/ML [4080418]

Facility

$0.25

Service Code	NDC 9994-0804-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

AMMONIUM LACTATE 12 % LOTION [10380]

Facility

$0.02

Service Code	NDC 0904598426
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

AMMONIUM LACTATE 12 % LOTION [10380]

Facility

$0.02

Service Code	NDC 0904598426
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

AMMONIUM LACTATE 5 % LOTION [10381]

Facility

$0.06

Service Code	NDC 1063128605
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

AMMONIUM LACTATE 5 % LOTION [10381]

Facility

$0.06

Service Code	NDC 1063128605
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION [453]

Facility

$0.03

Service Code	NDC 0143-9888-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION [453]

Facility

$0.03

Service Code	NDC 0143-9888-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]

Facility

$0.04

Service Code	NDC 0781-6041-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [454]

Facility

$0.04

Service Code	NDC 0781-6041-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$0.14

Service Code	NDC 0781-2020-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$0.14

Service Code	NDC 0781-2020-01
Hospital Charge Code	901700029
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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 Commercial	$0.11

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$0.06

Service Code	NDC 65862-016-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$0.06

Service Code	NDC 65862-016-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$0.06

Service Code	NDC 57237-030-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

AMOXICILLIN 250 MG CAPSULE [450]

Facility

$0.06

Service Code	NDC 57237-030-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]

Facility

$2.60

Service Code	NDC 42571-160-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]

Facility

$3.99

Service Code	NDC 0781-1874-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.39
Rate for Payer: Aetna of CA Government/Medicare	$2.39
Rate for Payer: Cash Price	$2.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.19
Rate for Payer: Health Smart Auto/Commercial	$2.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.39
Rate for Payer: LLUH Dept of Risk Management WC	$2.19
Rate for Payer: Multiplan Commercial	$2.99

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]

Facility

$2.60

Service Code	NDC 42571-160-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.56
Rate for Payer: Aetna of CA Government/Medicare	$1.56
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET [22992]

Facility

$3.99

Service Code	NDC 0781-1874-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.19
Rate for Payer: Cash Price	$2.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.19
Rate for Payer: Health Smart Auto/Commercial	$2.39
Rate for Payer: LLUH Dept of Risk Management WC	$2.19
Rate for Payer: Multiplan Commercial	$2.99

AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION [9080]

Facility

$0.81

Service Code	NDC 59651-026-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

Know your out-of-pocket cost for care.

All Charges