Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LACTULOSE 20 GRAM ORAL PACKET [24586]

Facility

$12.18

Service Code	NDC 66220-729-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$9.74
Rate for Payer: Cash Price	$6.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.74
Rate for Payer: Health Smart Auto/Commercial	$7.31
Rate for Payer: LLUH Dept of Risk Management WC	$6.70
Rate for Payer: Multiplan Commercial	$9.13

LACTULOSE 20 GRAM ORAL PACKET [24586]

Facility

$10.72

Service Code	NDC 0121-1930-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.90
Max. Negotiated Rate	$8.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.43
Rate for Payer: Aetna of CA Government/Medicare	$6.43
Rate for Payer: Cash Price	$5.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.58
Rate for Payer: Health Smart Auto/Commercial	$6.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.43
Rate for Payer: LLUH Dept of Risk Management WC	$5.90
Rate for Payer: Multiplan Commercial	$8.04

LACTULOSE 20 GRAM ORAL PACKET [24586]

Facility

$10.72

Service Code	NDC 0121-1930-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.90
Max. Negotiated Rate	$8.58
Rate for Payer: Cash Price	$5.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.58
Rate for Payer: Health Smart Auto/Commercial	$6.43
Rate for Payer: LLUH Dept of Risk Management WC	$5.90
Rate for Payer: Multiplan Commercial	$8.04

LACTULOSE 20 GRAM ORAL PACKET [24586]

Facility

$7.84

Service Code	NDC 66220-729-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$6.27
Rate for Payer: Cash Price	$4.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.27
Rate for Payer: Health Smart Auto/Commercial	$4.70
Rate for Payer: LLUH Dept of Risk Management WC	$4.31
Rate for Payer: Multiplan Commercial	$5.88

LAMIVUDINE 100 MG TABLET [24419]

Facility

$14.06

Service Code	NDC 60505-3250-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$7.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.25
Rate for Payer: Health Smart Auto/Commercial	$8.44
Rate for Payer: LLUH Dept of Risk Management WC	$7.73
Rate for Payer: Multiplan Commercial	$10.54

LAMIVUDINE 100 MG TABLET [24419]

Facility

$14.06

Service Code	NDC 60505-3250-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.44
Rate for Payer: Aetna of CA Government/Medicare	$8.44
Rate for Payer: Cash Price	$7.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.25
Rate for Payer: Health Smart Auto/Commercial	$8.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.44
Rate for Payer: LLUH Dept of Risk Management WC	$7.73
Rate for Payer: Multiplan Commercial	$10.54

LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]

Facility

$0.55

Service Code	NDC 49702-205-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]

Facility

$0.55

Service Code	NDC 49702-205-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

LAMIVUDINE 150 MG TABLET [15880]

Facility

$1.00

Service Code	NDC 33342-001-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

LAMIVUDINE 150 MG TABLET [15880]

Facility

$4.50

Service Code	NDC 60505-3251-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.70
Rate for Payer: Aetna of CA Government/Medicare	$2.70
Rate for Payer: Cash Price	$2.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.70
Rate for Payer: LLUH Dept of Risk Management WC	$2.48
Rate for Payer: Multiplan Commercial	$3.38

LAMIVUDINE 150 MG TABLET [15880]

Facility

$9.00

Service Code	NDC 60687-720-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

LAMIVUDINE 150 MG TABLET [15880]

Facility

$4.50

Service Code	NDC 60505-3251-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$3.60
Rate for Payer: Cash Price	$2.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.70
Rate for Payer: LLUH Dept of Risk Management WC	$2.48
Rate for Payer: Multiplan Commercial	$3.38

LAMIVUDINE 150 MG TABLET [15880]

Facility

$1.00

Service Code	NDC 33342-001-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

LAMIVUDINE 150 MG TABLET [15880]

Facility

$9.00

Service Code	NDC 60687-720-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

LAMIVUDINE 150 MG TABLET [15880]

Facility

$9.00

Service Code	NDC 60687-720-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

LAMIVUDINE 150 MG TABLET [15880]

Facility

$9.00

Service Code	NDC 60687-720-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

LAMIVUDINE 150 MG-ZIDOVUDINE 300 MG TABLET [21810]

Facility

$2.67

Service Code	NDC 31722-506-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.14
Rate for Payer: Cash Price	$1.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.14
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.47
Rate for Payer: Multiplan Commercial	$2.00

LAMIVUDINE 150 MG-ZIDOVUDINE 300 MG TABLET [21810]

Facility

$2.67

Service Code	NDC 31722-506-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.60
Rate for Payer: Aetna of CA Government/Medicare	$1.60
Rate for Payer: Cash Price	$1.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.14
Rate for Payer: Health Smart Auto/Commercial	$1.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.47
Rate for Payer: Multiplan Commercial	$2.00

LAMIVUDINE-ZIDOVUDINE ORAL SOLUTION COMPOUND [4080404]

Facility

$1.20

Service Code	NDC 9994-0804-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

LAMIVUDINE-ZIDOVUDINE ORAL SOLUTION COMPOUND [4080404]

Facility

$1.20

Service Code	NDC 9994-0804-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]

Facility

$6.38

Service Code	NDC 69918-370-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$5.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.83
Rate for Payer: Aetna of CA Government/Medicare	$3.83
Rate for Payer: Cash Price	$3.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.83
Rate for Payer: LLUH Dept of Risk Management WC	$3.51
Rate for Payer: Multiplan Commercial	$4.79

LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]

Facility

$9.73

Service Code	NDC 49884-486-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$7.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.84
Rate for Payer: Aetna of CA Government/Medicare	$5.84
Rate for Payer: Cash Price	$5.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.78
Rate for Payer: Health Smart Auto/Commercial	$5.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.84
Rate for Payer: LLUH Dept of Risk Management WC	$5.35
Rate for Payer: Multiplan Commercial	$7.30

LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]

Facility

$6.83

Service Code	NDC 43598-552-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$5.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.10
Rate for Payer: Aetna of CA Government/Medicare	$4.10
Rate for Payer: Cash Price	$3.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.46
Rate for Payer: Health Smart Auto/Commercial	$4.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.10
Rate for Payer: LLUH Dept of Risk Management WC	$3.76
Rate for Payer: Multiplan Commercial	$5.12

LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]

Facility

$6.38

Service Code	NDC 69918-370-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.83
Rate for Payer: LLUH Dept of Risk Management WC	$3.51
Rate for Payer: Multiplan Commercial	$4.79

LAMOTRIGINE 100 MG DISINTEGRATING TABLET [96941]

Facility

$9.73

Service Code	NDC 49884-486-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$7.78
Rate for Payer: Cash Price	$5.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.78
Rate for Payer: Health Smart Auto/Commercial	$5.84
Rate for Payer: LLUH Dept of Risk Management WC	$5.35
Rate for Payer: Multiplan Commercial	$7.30

Know your out-of-pocket cost for care.

All Charges