Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OSTOMY ADHESIVE PASTE [115464]

Facility

$0.16

Service Code	NDC 6845510690
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

OSTOMY SUPPLIES POWDER [110541]

Facility

$0.26

Service Code	NDC 6845510826
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

OSTOMY SUPPLIES POWDER [110541]

Facility

$0.26

Service Code	NDC 6845510826
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

OXACILLIN 10 GRAM SOLUTION FOR INJECTION [5925]

Facility

$133.20

Service Code	HCPCS J2700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$73.26
Max. Negotiated Rate	$106.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$79.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.10
Rate for Payer: Aetna of CA Government/Medicare	$79.92
Rate for Payer: Aetna of CA Government/Medicare	$84.10
Rate for Payer: Cash Price	$73.26
Rate for Payer: Cash Price	$77.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$106.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.13
Rate for Payer: Health Smart Auto/Commercial	$79.92
Rate for Payer: Health Smart Auto/Commercial	$84.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$79.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.10
Rate for Payer: LLUH Dept of Risk Management WC	$77.09
Rate for Payer: LLUH Dept of Risk Management WC	$73.26
Rate for Payer: Multiplan Commercial	$99.90
Rate for Payer: Multiplan Commercial	$105.12

OXACILLIN 10 GRAM SOLUTION FOR INJECTION [5925]

Facility

$133.20

Service Code	HCPCS J2700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$73.26
Max. Negotiated Rate	$106.56
Rate for Payer: Cash Price	$73.26
Rate for Payer: Cash Price	$77.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$106.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.13
Rate for Payer: Health Smart Auto/Commercial	$84.10
Rate for Payer: Health Smart Auto/Commercial	$79.92
Rate for Payer: LLUH Dept of Risk Management WC	$73.26
Rate for Payer: LLUH Dept of Risk Management WC	$77.09
Rate for Payer: Multiplan Commercial	$105.12
Rate for Payer: Multiplan Commercial	$99.90

OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]

Facility

$9.95

Service Code	HCPCS J2700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$7.96
Rate for Payer: Cash Price	$5.47
Rate for Payer: Cash Price	$7.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.96
Rate for Payer: Health Smart Auto/Commercial	$5.97
Rate for Payer: Health Smart Auto/Commercial	$8.14
Rate for Payer: LLUH Dept of Risk Management WC	$7.46
Rate for Payer: LLUH Dept of Risk Management WC	$5.47
Rate for Payer: Multiplan Commercial	$10.17
Rate for Payer: Multiplan Commercial	$7.46

OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]

Facility

$13.56

Service Code	HCPCS J2700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.97
Rate for Payer: Aetna of CA Government/Medicare	$5.97
Rate for Payer: Aetna of CA Government/Medicare	$8.14
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cash Price	$5.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.96
Rate for Payer: Health Smart Auto/Commercial	$8.14
Rate for Payer: Health Smart Auto/Commercial	$5.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.97
Rate for Payer: LLUH Dept of Risk Management WC	$5.47
Rate for Payer: LLUH Dept of Risk Management WC	$7.46
Rate for Payer: Multiplan Commercial	$10.17
Rate for Payer: Multiplan Commercial	$7.46

OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]

Facility

$27.12

Service Code	HCPCS J2700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.92
Max. Negotiated Rate	$21.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.82
Rate for Payer: Aetna of CA Government/Medicare	$6.48
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.82
Rate for Payer: Cash Price	$15.42
Rate for Payer: Cash Price	$14.92
Rate for Payer: Cash Price	$5.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.70
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Health Smart Auto/Commercial	$16.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.82
Rate for Payer: LLUH Dept of Risk Management WC	$15.42
Rate for Payer: LLUH Dept of Risk Management WC	$14.92
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$20.34
Rate for Payer: Multiplan Commercial	$21.02
Rate for Payer: Multiplan Commercial	$8.10

OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]

Facility

$10.80

Service Code	HCPCS J2700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cash Price	$15.42
Rate for Payer: Cash Price	$14.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.42
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Health Smart Auto/Commercial	$16.82
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: LLUH Dept of Risk Management WC	$15.42
Rate for Payer: LLUH Dept of Risk Management WC	$14.92
Rate for Payer: Multiplan Commercial	$20.34
Rate for Payer: Multiplan Commercial	$8.10
Rate for Payer: Multiplan Commercial	$21.02

OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]

Facility

$6.00

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$3.24
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$4.50

OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]

Facility

$6.00

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$2.59
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cash Price	$2.38
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.59
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$4.50

OXALIPLATIN 100 MG INTRAVENOUS SOLUTION [23929]

Facility

$126.48

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$69.56
Max. Negotiated Rate	$101.18
Rate for Payer: Cash Price	$69.56
Rate for Payer: Cash Price	$349.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$508.80
Rate for Payer: Health Smart Auto/Commercial	$75.89
Rate for Payer: Health Smart Auto/Commercial	$381.60
Rate for Payer: LLUH Dept of Risk Management WC	$349.80
Rate for Payer: LLUH Dept of Risk Management WC	$69.56
Rate for Payer: Multiplan Commercial	$94.86
Rate for Payer: Multiplan Commercial	$477.00

OXALIPLATIN 100 MG INTRAVENOUS SOLUTION [23929]

Facility

$126.48

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$69.56
Max. Negotiated Rate	$101.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$381.60
Rate for Payer: Aetna of CA Government/Medicare	$75.89
Rate for Payer: Aetna of CA Government/Medicare	$381.60
Rate for Payer: Cash Price	$69.56
Rate for Payer: Cash Price	$349.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$508.80
Rate for Payer: Health Smart Auto/Commercial	$75.89
Rate for Payer: Health Smart Auto/Commercial	$381.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$381.60
Rate for Payer: LLUH Dept of Risk Management WC	$349.80
Rate for Payer: LLUH Dept of Risk Management WC	$69.56
Rate for Payer: Multiplan Commercial	$94.86
Rate for Payer: Multiplan Commercial	$477.00

OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]

Facility

$3.60

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$4.50

OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]

Facility

$6.00

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50
Rate for Payer: Multiplan Commercial	$2.70

OXALIPLATIN 50 MG INTRAVENOUS SOLUTION [23928]

Facility

$318.00

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$174.90
Max. Negotiated Rate	$254.40
Rate for Payer: Cash Price	$174.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$254.40
Rate for Payer: Health Smart Auto/Commercial	$190.80
Rate for Payer: LLUH Dept of Risk Management WC	$174.90
Rate for Payer: Multiplan Commercial	$238.50

OXALIPLATIN 50 MG INTRAVENOUS SOLUTION [23928]

Facility

$318.00

Service Code	HCPCS J9263
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$174.90
Max. Negotiated Rate	$254.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$190.80
Rate for Payer: Aetna of CA Government/Medicare	$190.80
Rate for Payer: Cash Price	$174.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$254.40
Rate for Payer: Health Smart Auto/Commercial	$190.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$190.80
Rate for Payer: LLUH Dept of Risk Management WC	$174.90
Rate for Payer: Multiplan Commercial	$238.50

OXCARBAZEPINE 150 MG TABLET [27049]

Facility

$0.36

Service Code	NDC 62756-183-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
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: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

OXCARBAZEPINE 150 MG TABLET [27049]

Facility

$0.68

Service Code	NDC 0904-7262-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

OXCARBAZEPINE 150 MG TABLET [27049]

Facility

$0.36

Service Code	NDC 68462-137-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

OXCARBAZEPINE 150 MG TABLET [27049]

Facility

$0.68

Service Code	NDC 0904-7262-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

OXCARBAZEPINE 150 MG TABLET [27049]

Facility

$0.36

Service Code	NDC 68462-137-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
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: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

OXCARBAZEPINE 150 MG TABLET [27049]

Facility

$0.36

Service Code	NDC 62756-183-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION [30479]

Facility

$0.79

Service Code	NDC 65162-649-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION [30479]

Facility

$0.79

Service Code	NDC 65162-649-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

Know your out-of-pocket cost for care.

All Charges