Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.08

Service Code	NDC 23155-810-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.06

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.12

Service Code	NDC 23155-810-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.55

Service Code	NDC 60687-670-11
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

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.55

Service Code	NDC 60687-670-01
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

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.12

Service Code	NDC 69315-182-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.12

Service Code	NDC 23155-810-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.12

Service Code	NDC 69315-182-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.08

Service Code	NDC 23155-810-10
Hospital Charge Code	901700029
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	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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 Commercial	$0.06

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.11

Service Code	NDC 70954-005-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
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	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
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 Commercial	$0.08

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$0.30

Service Code	NDC 16729-318-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.23

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$0.30

Service Code	NDC 16729-318-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
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	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
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 Commercial	$0.23

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$0.89

Service Code	NDC 62175-271-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.71
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.49
Rate for Payer: Multiplan Commercial	$0.67

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$0.89

Service Code	NDC 62175-271-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.49
Rate for Payer: Multiplan Commercial	$0.67

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$0.42

Service Code	NDC 68382-256-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
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	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
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 Commercial	$0.32

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$0.42

Service Code	NDC 68382-256-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$3.67

Service Code	NDC 50268-628-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.20
Rate for Payer: Aetna of CA Government/Medicare	$2.20
Rate for Payer: Cash Price	$2.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.94
Rate for Payer: Health Smart Auto/Commercial	$2.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.20
Rate for Payer: LLUH Dept of Risk Management WC	$2.02
Rate for Payer: Multiplan Commercial	$2.75

OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [24471]

Facility

$3.67

Service Code	NDC 50268-628-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.94
Rate for Payer: Cash Price	$2.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.94
Rate for Payer: Health Smart Auto/Commercial	$2.20
Rate for Payer: LLUH Dept of Risk Management WC	$2.02
Rate for Payer: Multiplan Commercial	$2.75

OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]

Facility

$3.16

Service Code	NDC 50268-627-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]

Facility

$4.12

Service Code	NDC 0904-6570-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$2.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.09

OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]

Facility

$3.16

Service Code	NDC 50268-627-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR [24470]

Facility

$4.12

Service Code	NDC 0904-6570-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.47
Rate for Payer: Cash Price	$2.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.09

OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION [207355]

Facility

$3.44

Service Code	NDC 0327-0001-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.06
Rate for Payer: Aetna of CA Government/Medicare	$2.06
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.75
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.06
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: Multiplan Commercial	$2.58

OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION [207355]

Facility

$3.44

Service Code	NDC 0327-0001-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.75
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: Multiplan Commercial	$2.58

OXYCODONE 10 MG TABLET [87795]

Facility

$0.28

Service Code	NDC 42858-002-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

OXYCODONE 10 MG TABLET [87795]

Facility

$0.31

Service Code	NDC 0406-8510-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

Know your out-of-pocket cost for care.

All Charges