Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LAMOTRIGINE 150 MG TABLET [14266]

Facility

$0.13

Service Code	NDC 29300-113-16
Hospital Charge Code	1711640
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

LAMOTRIGINE 150 MG TABLET [14266]

Facility

$0.30

Service Code	NDC 68382-009-14
Hospital Charge Code	1711640
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

LAMOTRIGINE 150 MG TABLET [14266]

Facility

$0.11

Service Code	NDC 51672-4132-4
Hospital Charge Code	1711640
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

LAMOTRIGINE 200 MG DISINTEGRATING TABLET [96942]

Facility

$10.84

Service Code	NDC 43598-553-30
Hospital Charge Code	1712437
Hospital Revenue Code	259
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$8.67
Rate for Payer: Cash Price	$4.88
Rate for Payer: Cigna of CA HMO/PPO	$8.67
Rate for Payer: Health Smart Auto/Commercial	$6.50
Rate for Payer: LLUH Dept of Risk Management WC	$5.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.13

LAMOTRIGINE 200 MG DISINTEGRATING TABLET [96942]

Facility

$11.61

Service Code	NDC 49884-487-54
Hospital Charge Code	1712437
Hospital Revenue Code	259
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$9.29
Rate for Payer: Cash Price	$5.22
Rate for Payer: Cigna of CA HMO/PPO	$9.29
Rate for Payer: Health Smart Auto/Commercial	$6.97
Rate for Payer: LLUH Dept of Risk Management WC	$6.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.71

LAMOTRIGINE 200 MG DISINTEGRATING TABLET [96942]

Facility

$10.84

Service Code	NDC 43598-553-30
Hospital Charge Code	1712437
Hospital Revenue Code	259
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$8.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.50
Rate for Payer: Aetna of CA Government/Medicare	$6.50
Rate for Payer: Cash Price	$4.88
Rate for Payer: Health Smart Auto/Commercial	$6.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.50
Rate for Payer: LLUH Dept of Risk Management WC	$5.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.13

LAMOTRIGINE 200 MG DISINTEGRATING TABLET [96942]

Facility

$11.61

Service Code	NDC 49884-487-54
Hospital Charge Code	1712437
Hospital Revenue Code	259
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$8.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.97
Rate for Payer: Aetna of CA Government/Medicare	$6.97
Rate for Payer: Cash Price	$5.22
Rate for Payer: Health Smart Auto/Commercial	$6.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.97
Rate for Payer: LLUH Dept of Risk Management WC	$6.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.71

LAMOTRIGINE 200 MG DISINTEGRATING TABLET [96942]

Facility

$11.61

Service Code	NDC 49884-487-11
Hospital Charge Code	1712437
Hospital Revenue Code	259
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$8.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.97
Rate for Payer: Aetna of CA Government/Medicare	$6.97
Rate for Payer: Cash Price	$5.22
Rate for Payer: Health Smart Auto/Commercial	$6.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.97
Rate for Payer: LLUH Dept of Risk Management WC	$6.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.71

LAMOTRIGINE 200 MG DISINTEGRATING TABLET [96942]

Facility

$11.61

Service Code	NDC 49884-487-11
Hospital Charge Code	1712437
Hospital Revenue Code	259
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$9.29
Rate for Payer: Cash Price	$5.22
Rate for Payer: Cigna of CA HMO/PPO	$9.29
Rate for Payer: Health Smart Auto/Commercial	$6.97
Rate for Payer: LLUH Dept of Risk Management WC	$6.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.71

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.17

Service Code	NDC 51672-4133-4
Hospital Charge Code	1711641
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

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.25

Service Code	NDC 51079-866-01
Hospital Charge Code	1711641
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.19

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.25

Service Code	NDC 51079-866-01
Hospital Charge Code	1711641
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
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	$0.11
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 Beech St/Commercial/PHCS	$0.19

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.17

Service Code	NDC 29300-114-16
Hospital Charge Code	1711641
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

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.17

Service Code	NDC 29300-114-16
Hospital Charge Code	1711641
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

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.17

Service Code	NDC 13668-049-60
Hospital Charge Code	1711641
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

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.17

Service Code	NDC 13668-049-60
Hospital Charge Code	1711641
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

LAMOTRIGINE 200 MG TABLET [13983]

Facility

$0.17

Service Code	NDC 51672-4133-4
Hospital Charge Code	1711641
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

LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]

Facility

$0.53

Service Code	NDC 62332-096-31
Hospital Charge Code	1711994
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

LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]

Facility

$0.53

Service Code	NDC 62332-096-31
Hospital Charge Code	1711994
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

LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]

Facility

$0.53

Service Code	NDC 68462-229-01
Hospital Charge Code	1711994
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

LAMOTRIGINE 25 MG CHEWABLE DISPERSIBLE TABLET [103880]

Facility

$0.53

Service Code	NDC 68462-229-01
Hospital Charge Code	1711994
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

LAMOTRIGINE 25 MG DISINTEGRATING TABLET [97830]

Facility

$16.07

Service Code	NDC 0173-0772-02
Hospital Charge Code	1712434
Hospital Revenue Code	259
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$12.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.64
Rate for Payer: Aetna of CA Government/Medicare	$9.64
Rate for Payer: Cash Price	$7.23
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.64
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.05

LAMOTRIGINE 25 MG DISINTEGRATING TABLET [97830]

Facility

$16.07

Service Code	NDC 0173-0772-02
Hospital Charge Code	1712434
Hospital Revenue Code	259
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$12.86
Rate for Payer: Cash Price	$7.23
Rate for Payer: Cigna of CA HMO/PPO	$12.86
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.05

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.07

Service Code	NDC 29300-111-01
Hospital Charge Code	1711638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

LAMOTRIGINE 25 MG TABLET [13981]

Facility

$0.22

Service Code	NDC 68084-318-11
Hospital Charge Code	1711638
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

Know your out-of-pocket cost for care.

All Charges