Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$0.11

Service Code	NDC 65862-017-01
Hospital Charge Code	1710442
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$0.21

Service Code	NDC 0781-2613-01
Hospital Charge Code	1710442
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$0.11

Service Code	NDC 65862-017-01
Hospital Charge Code	1710442
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
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	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

AMOXICILLIN 500 MG CAPSULE [451]

Facility

$0.22

Service Code	NDC 0093-3109-53
Hospital Charge Code	1710442
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$0.53

Service Code	NDC 65862-502-20
Hospital Charge Code	1711388
Hospital Revenue Code	259
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

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$0.60

Service Code	NDC 42571-161-01
Hospital Charge Code	1711388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$1.14

Service Code	NDC 66685-1002-2
Hospital Charge Code	1711388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.86

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$1.14

Service Code	NDC 0781-1831-20
Hospital Charge Code	1711388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.91
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.86

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$1.14

Service Code	NDC 0781-1831-20
Hospital Charge Code	1711388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.86

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$1.14

Service Code	NDC 66685-1002-2
Hospital Charge Code	1711388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.91
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.86

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$0.60

Service Code	NDC 42571-161-01
Hospital Charge Code	1711388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33227]

Facility

$0.53

Service Code	NDC 65862-502-20
Hospital Charge Code	1711388
Hospital Revenue Code	259
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

AMOXICILLIN 500 MG TABLET [17456]

Facility

$0.42

Service Code	NDC 65862-014-01
Hospital Charge Code	ERX17456
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
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	$0.19
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 Beech St/Commercial/PHCS	$0.32

AMOXICILLIN 500 MG TABLET [17456]

Facility

$0.42

Service Code	NDC 65862-014-01
Hospital Charge Code	ERX17456
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$0.72

Service Code	NDC 42571-162-01
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$0.72

Service Code	NDC 42571-162-42
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$1.36

Service Code	NDC 0781-1852-01
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.02
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	$0.61
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	$1.02

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$1.36

Service Code	NDC 0781-1852-20
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.02
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	$0.61
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	$1.02

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$1.36

Service Code	NDC 66685-1001-1
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.02
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	$0.61
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	$1.02

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$0.72

Service Code	NDC 42571-162-01
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$0.58

Service Code	NDC 65862-503-01
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$1.36

Service Code	NDC 0781-1852-20
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.09
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cigna of CA HMO/PPO	$1.09
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	$1.02

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$0.44

Service Code	NDC 65862-503-20
Hospital Charge Code	1711674
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

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$1.36

Service Code	NDC 0781-1852-01
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.09
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cigna of CA HMO/PPO	$1.09
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	$1.02

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]

Facility

$0.72

Service Code	NDC 42571-162-42
Hospital Charge Code	1711674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

Know your out-of-pocket cost for care.

All Charges