Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

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

$1.42

Service Code	NDC 60687-406-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.85
Rate for Payer: Aetna of CA Government/Medicare	$0.85
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Commercial	$1.06

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.49

Service Code	NDC 0121-4827-40
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 0121-4827-40
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

OXYCODONE 5 MG TABLET [10814]

Facility

$0.39

Service Code	NDC 0904-6966-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

OXYCODONE 5 MG TABLET [10814]

Facility

$0.16

Service Code	NDC 10702-018-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 42858-001-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.39

Service Code	NDC 0904-6966-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-11
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

OXYCODONE 5 MG TABLET [10814]

Facility

$0.24

Service Code	NDC 0406-0552-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

OXYCODONE 5 MG TABLET [10814]

Facility

$0.60

Service Code	NDC 0406-0552-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 0406-0552-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.24

Service Code	NDC 0406-0552-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-01
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

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-11
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

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 42858-001-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.16

Service Code	NDC 10702-018-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
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

OXYCODONE 5 MG TABLET [10814]

Facility

$0.60

Service Code	NDC 0406-0552-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 0406-0552-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-01
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

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

$0.59

Service Code	NDC 0406-0523-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

$2.06

Service Code	NDC 68084-710-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.24
Rate for Payer: Aetna of CA Government/Medicare	$1.24
Rate for Payer: Cash Price	$1.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.65
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.13
Rate for Payer: Multiplan Commercial	$1.54

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

$2.06

Service Code	NDC 68084-710-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.24
Rate for Payer: Aetna of CA Government/Medicare	$1.24
Rate for Payer: Cash Price	$1.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.65
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.13
Rate for Payer: Multiplan Commercial	$1.54

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

$0.59

Service Code	NDC 0406-0523-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

Know your out-of-pocket cost for care.

All Charges