Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.04

Service Code	NDC 0904-6730-61
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 57896-201-10
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.04

Service Code	NDC 0904-6730-61
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 57896-204-01
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 57896-204-01
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 57896-201-01
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 57896-201-01
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 0904-6730-80
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 57896-201-10
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

$0.02

Service Code	NDC 0904-6730-80
Hospital Charge Code	1711186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

$0.34

Service Code	NDC 45802-730-32
Hospital Charge Code	1748012
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

$0.34

Service Code	NDC 45802-730-00
Hospital Charge Code	1748012
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

$0.34

Service Code	NDC 45802-730-32
Hospital Charge Code	1748012
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

$0.34

Service Code	NDC 45802-730-00
Hospital Charge Code	1748012
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]

Facility

$0.08

Service Code	NDC 0904-5791-46
Hospital Charge Code	1711191
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

ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]

Facility

$0.08

Service Code	NDC 0904-5791-46
Hospital Charge Code	1711191
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

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$0.84

Service Code	NDC 51672-2114-0
Hospital Charge Code	1711987
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$0.84

Service Code	NDC 51672-2114-0
Hospital Charge Code	1711987
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$0.84

Service Code	NDC 51672-2114-2
Hospital Charge Code	1711987
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

$0.84

Service Code	NDC 51672-2114-2
Hospital Charge Code	1711987
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$4.19

Service Code	NDC 68084-541-11
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.51
Rate for Payer: Aetna of CA Government/Medicare	$2.51
Rate for Payer: Cash Price	$1.89
Rate for Payer: Health Smart Auto/Commercial	$2.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.51
Rate for Payer: LLUH Dept of Risk Management WC	$2.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.14

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$1.20

Service Code	NDC 0527-1050-01
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.90

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$0.42

Service Code	NDC 70756-721-11
Hospital Charge Code	1710302
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

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$4.19

Service Code	NDC 68084-541-01
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.35
Rate for Payer: Cash Price	$1.89
Rate for Payer: Cigna of CA HMO/PPO	$3.35
Rate for Payer: Health Smart Auto/Commercial	$2.51
Rate for Payer: LLUH Dept of Risk Management WC	$2.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.14

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

$27.68

Service Code	NDC 51672-4023-1
Hospital Charge Code	1710302
Hospital Revenue Code	259
Min. Negotiated Rate	$15.22
Max. Negotiated Rate	$20.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.61
Rate for Payer: Aetna of CA Government/Medicare	$16.61
Rate for Payer: Cash Price	$12.46
Rate for Payer: Health Smart Auto/Commercial	$16.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.61
Rate for Payer: LLUH Dept of Risk Management WC	$15.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.76

Know your out-of-pocket cost for care.

All Charges