Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OXYCODONE 10 MG TABLET [87795]

Facility

$0.86

Service Code	NDC 68084-968-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

OXYCODONE 10 MG TABLET [87795]

Facility

$0.94

Service Code	NDC 0406-8510-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

OXYCODONE 10 MG TABLET [87795]

Facility

$0.86

Service Code	NDC 68084-968-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

OXYCODONE 10 MG TABLET [87795]

Facility

$0.94

Service Code	NDC 0406-8510-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
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	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
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	$0.52
Rate for Payer: Multiplan Commercial	$0.71

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: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.94

Service Code	NDC 0406-8510-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
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	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
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	$0.52
Rate for Payer: Multiplan Commercial	$0.71

OXYCODONE 10 MG TABLET [87795]

Facility

$0.86

Service Code	NDC 68084-968-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

OXYCODONE 10 MG TABLET [87795]

Facility

$0.86

Service Code	NDC 68084-968-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65

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: 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: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

OXYCODONE 10 MG TABLET [87795]

Facility

$0.94

Service Code	NDC 0406-8510-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.22
Rate for Payer: Aetna of CA Government/Medicare	$4.22
Rate for Payer: Cash Price	$3.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.63
Rate for Payer: Health Smart Auto/Commercial	$4.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.22
Rate for Payer: LLUH Dept of Risk Management WC	$3.87
Rate for Payer: Multiplan Commercial	$5.28

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$5.60

Service Code	NDC 71930-023-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.63
Rate for Payer: Cash Price	$3.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.63
Rate for Payer: Health Smart Auto/Commercial	$4.22
Rate for Payer: LLUH Dept of Risk Management WC	$3.87
Rate for Payer: Multiplan Commercial	$5.28

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$5.60

Service Code	NDC 71930-023-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.36
Rate for Payer: Aetna of CA Government/Medicare	$3.36
Rate for Payer: Cash Price	$3.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.48
Rate for Payer: Health Smart Auto/Commercial	$3.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.36
Rate for Payer: LLUH Dept of Risk Management WC	$3.08
Rate for Payer: Multiplan Commercial	$4.20

OXYCODONE 20 MG/ML ORAL SOLUTION. [4081621]

Facility

$4.40

Service Code	NDC 0406-8557-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Cash Price	$2.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Commercial	$3.30

OXYCODONE 20 MG/ML ORAL SOLUTION. [4081621]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.63
Rate for Payer: Cash Price	$3.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.63
Rate for Payer: Health Smart Auto/Commercial	$4.22
Rate for Payer: LLUH Dept of Risk Management WC	$3.87
Rate for Payer: Multiplan Commercial	$5.28

OXYCODONE 20 MG/ML ORAL SOLUTION. [4081621]

Facility

$4.40

Service Code	NDC 0406-8557-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.52
Rate for Payer: Cash Price	$2.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Commercial	$3.30

OXYCODONE 20 MG/ML ORAL SOLUTION. [4081621]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.22
Rate for Payer: Aetna of CA Government/Medicare	$4.22
Rate for Payer: Cash Price	$3.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.63
Rate for Payer: Health Smart Auto/Commercial	$4.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.22
Rate for Payer: LLUH Dept of Risk Management WC	$3.87
Rate for Payer: Multiplan Commercial	$5.28

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 0904-6678-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 0904-6678-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.15

Service Code	NDC 0406-8556-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 9999-9108-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 9999-9108-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.49

Service Code	NDC 0121-4827-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.89
Rate for Payer: Aetna of CA Government/Medicare	$0.89
Rate for Payer: Cash Price	$0.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.19
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.82
Rate for Payer: Multiplan Commercial	$1.12

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.49

Service Code	NDC 0121-4827-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.19
Rate for Payer: Cash Price	$0.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.19
Rate for Payer: Health Smart Auto/Commercial	$0.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.82
Rate for Payer: Multiplan Commercial	$1.12

Know your out-of-pocket cost for care.

All Charges