Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]

Facility

$0.26

Service Code	CPT J1953
Hospital Charge Code	NDG154435
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.08

Service Code	NDC 60432-831-16
Hospital Charge Code	1715766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.11

Service Code	NDC 31722-574-47
Hospital Charge Code	1715766
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

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.08

Service Code	NDC 60432-831-16
Hospital Charge Code	1715766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.08

Service Code	NDC 71093-144-13
Hospital Charge Code	1715766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.08

Service Code	NDC 71093-144-13
Hospital Charge Code	1715766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.15

Service Code	NDC 50383-241-16
Hospital Charge Code	1715766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.15

Service Code	NDC 50383-241-16
Hospital Charge Code	1715766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]

Facility

$0.11

Service Code	NDC 31722-574-47
Hospital Charge Code	1715766
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

LEVETIRACETAM 250 MG TABLET [26816]

Facility

$0.30

Service Code	NDC 68084-859-01
Hospital Charge Code	1712236
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

LEVETIRACETAM 250 MG TABLET [26816]

Facility

$0.30

Service Code	NDC 68084-859-11
Hospital Charge Code	1712236
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

LEVETIRACETAM 250 MG TABLET [26816]

Facility

$0.30

Service Code	NDC 68084-859-11
Hospital Charge Code	1712236
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

LEVETIRACETAM 250 MG TABLET [26816]

Facility

$0.30

Service Code	NDC 68084-859-01
Hospital Charge Code	1712236
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

LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]

Facility

$0.17

Service Code	CPT J1953
Hospital Charge Code	NDG154437
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]

Facility

$0.10

Service Code	CPT J1953
Hospital Charge Code	NDG154437
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
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: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$0.93

Service Code	NDC 0409-1886-22
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.70

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$0.93

Service Code	NDC 0409-1886-02
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.70

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$1.08

Service Code	NDC 43547-454-10
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$1.08

Service Code	NDC 43547-454-10
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$1.89

Service Code	NDC 63323-400-01
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.13
Rate for Payer: Aetna of CA Government/Medicare	$1.13
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.42

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$1.89

Service Code	NDC 63323-400-01
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.51
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cigna of CA HMO/PPO	$1.51
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.42

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$0.93

Service Code	NDC 0409-1886-22
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cigna of CA HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.70

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$1.08

Service Code	NDC 43547-454-41
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$2.52

Service Code	NDC 67457-790-00
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.51
Rate for Payer: Aetna of CA Government/Medicare	$1.51
Rate for Payer: Cash Price	$1.13
Rate for Payer: Health Smart Auto/Commercial	$1.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.51
Rate for Payer: LLUH Dept of Risk Management WC	$1.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.89

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

$1.08

Service Code	NDC 43547-454-41
Hospital Charge Code	1722045
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

Know your out-of-pocket cost for care.

All Charges