Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]

Facility

$8.09

Service Code	NDC 0781-1943-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.85
Rate for Payer: Aetna of CA Government/Medicare	$4.85
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]

Facility

$8.09

Service Code	NDC 0781-1943-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]

Facility

$8.04

Service Code	NDC 43598-020-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$6.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.82
Rate for Payer: Aetna of CA Government/Medicare	$4.82
Rate for Payer: Cash Price	$4.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.43
Rate for Payer: Health Smart Auto/Commercial	$4.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.82
Rate for Payer: LLUH Dept of Risk Management WC	$4.42
Rate for Payer: Multiplan Commercial	$6.03

AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]

Facility

$8.04

Service Code	NDC 43598-020-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$6.43
Rate for Payer: Cash Price	$4.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.43
Rate for Payer: Health Smart Auto/Commercial	$4.82
Rate for Payer: LLUH Dept of Risk Management WC	$4.42
Rate for Payer: Multiplan Commercial	$6.03

AMOXICILLIN-POTASSIUM CLAVULANATE 1,000 MG-62.5 MG TABLET,EXT.REL 12HR [33862]

Facility

$8.09

Service Code	NDC 0781-1943-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$6.47
Rate for Payer: Cash Price	$4.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.47
Rate for Payer: Health Smart Auto/Commercial	$4.85
Rate for Payer: LLUH Dept of Risk Management WC	$4.45
Rate for Payer: Multiplan Commercial	$6.07

AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [464]

Facility

$57.60

Service Code	HCPCS J0285
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$31.68
Max. Negotiated Rate	$46.08
Rate for Payer: Cash Price	$31.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$46.08
Rate for Payer: Health Smart Auto/Commercial	$34.56
Rate for Payer: LLUH Dept of Risk Management WC	$31.68
Rate for Payer: Multiplan Commercial	$43.20

AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [464]

Facility

$57.60

Service Code	HCPCS J0285
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$31.68
Max. Negotiated Rate	$46.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$34.56
Rate for Payer: Aetna of CA Government/Medicare	$34.56
Rate for Payer: Cash Price	$31.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$46.08
Rate for Payer: Health Smart Auto/Commercial	$34.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$34.56
Rate for Payer: LLUH Dept of Risk Management WC	$31.68
Rate for Payer: Multiplan Commercial	$43.20

AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]

Facility

$381.97

Service Code	HCPCS J0289
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$210.08
Max. Negotiated Rate	$305.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$229.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$171.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$183.42
Rate for Payer: Aetna of CA Government/Medicare	$171.86
Rate for Payer: Aetna of CA Government/Medicare	$183.42
Rate for Payer: Aetna of CA Government/Medicare	$229.18
Rate for Payer: Cash Price	$168.14
Rate for Payer: Cash Price	$157.54
Rate for Payer: Cash Price	$210.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$305.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$229.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$244.56
Rate for Payer: Health Smart Auto/Commercial	$229.18
Rate for Payer: Health Smart Auto/Commercial	$183.42
Rate for Payer: Health Smart Auto/Commercial	$171.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$229.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$183.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$171.86
Rate for Payer: LLUH Dept of Risk Management WC	$157.54
Rate for Payer: LLUH Dept of Risk Management WC	$168.13
Rate for Payer: LLUH Dept of Risk Management WC	$210.08
Rate for Payer: Multiplan Commercial	$229.28
Rate for Payer: Multiplan Commercial	$214.83
Rate for Payer: Multiplan Commercial	$286.48

AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]

Facility

$286.44

Service Code	HCPCS J0289
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$157.54
Max. Negotiated Rate	$229.15
Rate for Payer: Cash Price	$157.54
Rate for Payer: Cash Price	$210.08
Rate for Payer: Cash Price	$168.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$305.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$229.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$244.56
Rate for Payer: Health Smart Auto/Commercial	$229.18
Rate for Payer: Health Smart Auto/Commercial	$183.42
Rate for Payer: Health Smart Auto/Commercial	$171.86
Rate for Payer: LLUH Dept of Risk Management WC	$210.08
Rate for Payer: LLUH Dept of Risk Management WC	$157.54
Rate for Payer: LLUH Dept of Risk Management WC	$168.13
Rate for Payer: Multiplan Commercial	$286.48
Rate for Payer: Multiplan Commercial	$229.28
Rate for Payer: Multiplan Commercial	$214.83

AMPHOTERICIN ORAL SUSPENSION COMPOUND 5 MG/ML [4080241]

Facility

$4.56

Service Code	NDC 9994-0802-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$3.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.74
Rate for Payer: Aetna of CA Government/Medicare	$2.74
Rate for Payer: Cash Price	$2.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.65
Rate for Payer: Health Smart Auto/Commercial	$2.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.74
Rate for Payer: LLUH Dept of Risk Management WC	$2.51
Rate for Payer: Multiplan Commercial	$3.42

AMPHOTERICIN ORAL SUSPENSION COMPOUND 5 MG/ML [4080241]

Facility

$4.56

Service Code	NDC 9994-0802-41
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$3.65
Rate for Payer: Cash Price	$2.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.65
Rate for Payer: Health Smart Auto/Commercial	$2.74
Rate for Payer: LLUH Dept of Risk Management WC	$2.51
Rate for Payer: Multiplan Commercial	$3.42

AMPICILLIN 10 GRAM SOLUTION FOR INJECTION [470]

Facility

$90.00

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$46.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.66
Rate for Payer: Aetna of CA Government/Medicare	$46.80
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$49.66
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$45.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$62.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.22
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: Health Smart Auto/Commercial	$49.66
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$46.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$45.52
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$58.50
Rate for Payer: Multiplan Commercial	$62.08
Rate for Payer: Multiplan Commercial	$67.50

AMPICILLIN 10 GRAM SOLUTION FOR INJECTION [470]

Facility

$90.00

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$45.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$62.40
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: Health Smart Auto/Commercial	$49.66
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: LLUH Dept of Risk Management WC	$45.52
Rate for Payer: Multiplan Commercial	$58.50
Rate for Payer: Multiplan Commercial	$62.08
Rate for Payer: Multiplan Commercial	$67.50

AMPICILLIN 1G/50ML NS IV ADMIXTURE KIT (ADSOK) [200002]

Facility

$7.08

Service Code	NDC 9999-2000-02
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$5.66
Rate for Payer: Cash Price	$3.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.66
Rate for Payer: Health Smart Auto/Commercial	$4.25
Rate for Payer: LLUH Dept of Risk Management WC	$3.89
Rate for Payer: Multiplan Commercial	$5.31

AMPICILLIN 1G/50ML NS IV ADMIXTURE KIT (ADSOK) [200002]

Facility

$7.08

Service Code	NDC 9999-2000-02
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$5.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.25
Rate for Payer: Aetna of CA Government/Medicare	$4.25
Rate for Payer: Cash Price	$3.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.66
Rate for Payer: Health Smart Auto/Commercial	$4.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.25
Rate for Payer: LLUH Dept of Risk Management WC	$3.89
Rate for Payer: Multiplan Commercial	$5.31

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]

Facility

$7.20

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.98
Rate for Payer: Aetna of CA Government/Medicare	$3.49
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$3.98
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cash Price	$3.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.30
Rate for Payer: Health Smart Auto/Commercial	$3.49
Rate for Payer: Health Smart Auto/Commercial	$3.98
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.65
Rate for Payer: LLUH Dept of Risk Management WC	$3.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Commercial	$4.36
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Commercial	$5.40

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]

Facility

$7.20

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cash Price	$3.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.65
Rate for Payer: Health Smart Auto/Commercial	$3.49
Rate for Payer: Health Smart Auto/Commercial	$3.98
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$3.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.65
Rate for Payer: Multiplan Commercial	$4.36
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Commercial	$5.40

AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]

Facility

$8.53

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.69
Max. Negotiated Rate	$6.82
Rate for Payer: Cash Price	$4.69
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.86
Rate for Payer: Health Smart Auto/Commercial	$9.65
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Health Smart Auto/Commercial	$5.12
Rate for Payer: LLUH Dept of Risk Management WC	$4.69
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$12.06
Rate for Payer: Multiplan Commercial	$3.15
Rate for Payer: Multiplan Commercial	$6.40

AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]

Facility

$8.53

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.69
Max. Negotiated Rate	$6.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$9.65
Rate for Payer: Aetna of CA Government/Medicare	$5.12
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cash Price	$4.69
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$9.65
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Health Smart Auto/Commercial	$5.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.12
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: LLUH Dept of Risk Management WC	$4.69
Rate for Payer: Multiplan Commercial	$12.06
Rate for Payer: Multiplan Commercial	$3.15
Rate for Payer: Multiplan Commercial	$6.40

AMPICILLIN 500 MG CAPSULE [466]

Facility

$0.62

Service Code	NDC 0781-2145-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

AMPICILLIN 500 MG CAPSULE [466]

Facility

$0.62

Service Code	NDC 0781-2145-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]

Facility

$3.38

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.03
Rate for Payer: Aetna of CA Government/Medicare	$2.03
Rate for Payer: Cash Price	$1.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.70
Rate for Payer: Health Smart Auto/Commercial	$2.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.03
Rate for Payer: LLUH Dept of Risk Management WC	$1.86
Rate for Payer: Multiplan Commercial	$2.54

AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]

Facility

$3.38

Service Code	HCPCS J0290
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.70
Rate for Payer: Cash Price	$1.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.70
Rate for Payer: Health Smart Auto/Commercial	$2.03
Rate for Payer: LLUH Dept of Risk Management WC	$1.86
Rate for Payer: Multiplan Commercial	$2.54

AMPICILLIN-SULBACTAM 15 GRAM SOLUTION FOR INJECTION [32469]

Facility

$87.37

Service Code	HCPCS J0295
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$69.90
Rate for Payer: Cash Price	$48.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.90
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Commercial	$65.53

AMPICILLIN-SULBACTAM 15 GRAM SOLUTION FOR INJECTION [32469]

Facility

$87.37

Service Code	HCPCS J0295
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$69.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.42
Rate for Payer: Aetna of CA Government/Medicare	$52.42
Rate for Payer: Cash Price	$48.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.90
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Commercial	$65.53

Know your out-of-pocket cost for care.

All Charges