Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]

Facility

$0.15

Service Code	NDC 0832-0038-00
Hospital Charge Code	1710316
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$3.67

Service Code	NDC 50268-628-15
Hospital Charge Code	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.75
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	$1.65
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 Beech St/Commercial/PHCS	$2.75

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

Facility

$0.89

Service Code	NDC 62175-271-37
Hospital Charge Code	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.71
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.67

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

Facility

$3.67

Service Code	NDC 50268-628-15
Hospital Charge Code	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.94
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.75

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

Facility

$0.42

Service Code	NDC 68382-256-01
Hospital Charge Code	1711989
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

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

Facility

$0.30

Service Code	NDC 16729-318-01
Hospital Charge Code	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
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	$0.14
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 Beech St/Commercial/PHCS	$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	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.67
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	$0.40
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 Beech St/Commercial/PHCS	$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	1711989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

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

Facility

$0.89

Service Code	NDC 62175-270-37
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.71
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.67

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

Facility

$0.19

Service Code	NDC 65162-371-10
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

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

Facility

$0.89

Service Code	NDC 62175-270-37
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.67
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	$0.40
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 Beech St/Commercial/PHCS	$0.67

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

Facility

$3.27

Service Code	NDC 51079-722-01
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.96
Rate for Payer: Aetna of CA Government/Medicare	$1.96
Rate for Payer: Cash Price	$1.47
Rate for Payer: Health Smart Auto/Commercial	$1.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.45

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

Facility

$3.27

Service Code	NDC 51079-722-01
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$2.62
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cigna of CA HMO/PPO	$2.62
Rate for Payer: Health Smart Auto/Commercial	$1.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.45

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

Facility

$3.16

Service Code	NDC 50268-627-15
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.42
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.37

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

Facility

$3.16

Service Code	NDC 50268-627-15
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.37
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	$1.42
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 Beech St/Commercial/PHCS	$2.37

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

Facility

$0.19

Service Code	NDC 65162-371-10
Hospital Charge Code	1710880
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION [207355]

Facility

$3.36

Service Code	NDC 0327-0001-10
Hospital Charge Code	1743758
Hospital Revenue Code	259
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.02
Rate for Payer: Aetna of CA Government/Medicare	$2.02
Rate for Payer: Cash Price	$1.51
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION [207355]

Facility

$3.36

Service Code	NDC 0327-0001-10
Hospital Charge Code	1743758
Hospital Revenue Code	259
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.69
Rate for Payer: Cash Price	$1.51
Rate for Payer: Cigna of CA HMO/PPO	$2.69
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]

Facility

$4.49

Service Code	NDC 68094-801-58
Hospital Charge Code	NDG215181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$3.59
Rate for Payer: Cash Price	$2.02
Rate for Payer: Cigna of CA HMO/PPO	$3.59
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.37

OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]

Facility

$4.49

Service Code	NDC 68094-801-01
Hospital Charge Code	NDG215181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$3.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.69
Rate for Payer: Aetna of CA Government/Medicare	$2.69
Rate for Payer: Cash Price	$2.02
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.37

OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]

Facility

$4.49

Service Code	NDC 68094-801-58
Hospital Charge Code	NDG215181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$3.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.69
Rate for Payer: Aetna of CA Government/Medicare	$2.69
Rate for Payer: Cash Price	$2.02
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.37

OXYCODONE 10 MG/0.5 ML ORAL SYRINGE (FOR ORAL USE ONLY) [215181]

Facility

$4.49

Service Code	NDC 68094-801-01
Hospital Charge Code	NDG215181
Hospital Revenue Code	259
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$3.59
Rate for Payer: Cash Price	$2.02
Rate for Payer: Cigna of CA HMO/PPO	$3.59
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.37

OXYCODONE 10 MG TABLET [87795]

Facility

$0.17

Service Code	NDC 10702-056-01
Hospital Charge Code	ERX87795
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

OXYCODONE 10 MG TABLET [87795]

Facility

$0.17

Service Code	NDC 99702-056-01
Hospital Charge Code	ERX87795
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	$0.08
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 Beech St/Commercial/PHCS	$0.13

Know your out-of-pocket cost for care.

All Charges