Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OXYCODONE 10 MG TABLET [87795]

Facility

$0.15

Service Code	NDC 42858-002-01
Hospital Charge Code	ERX87795
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

OXYCODONE 10 MG TABLET [87795]

Facility

$0.15

Service Code	NDC 42858-002-01
Hospital Charge Code	ERX87795
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

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

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	$0.13
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

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$5.60

Service Code	NDC 71930-023-30
Hospital Charge Code	NDG10812
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.20
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	$2.52
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 Beech St/Commercial/PHCS	$4.20

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	1734050
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.63
Rate for Payer: Cash Price	$3.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$5.28

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$5.60

Service Code	NDC 71930-023-30
Hospital Charge Code	NDG10812
Hospital Revenue Code	259
Min. Negotiated Rate	$3.08
Max. Negotiated Rate	$4.48
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$4.20

OXYCODONE 20 MG/ML ORAL CONCENTRATE [10812]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	1734050
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.28
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	$3.17
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 Beech St/Commercial/PHCS	$5.28

OXYCODONE 20 MG/ML ORAL SOLUTION. [4081621]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	1734050
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.63
Rate for Payer: Cash Price	$3.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$5.28

OXYCODONE 20 MG/ML ORAL SOLUTION. [4081621]

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 20 MG/ML ORAL SOLUTION. [4081621]

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 20 MG/ML ORAL SOLUTION. [4081621]

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 20 MG/ML ORAL SOLUTION. [4081621]

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 20 MG/ML ORAL SOLUTION. [4081621]

Facility

$7.04

Service Code	NDC 9999-9108-12
Hospital Charge Code	1734050
Hospital Revenue Code	259
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$5.28
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	$3.17
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 Beech St/Commercial/PHCS	$5.28

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.66

Service Code	NDC 66689-401-50
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna of CA HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.66

Service Code	NDC 66689-401-01
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna of CA HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.42

Service Code	NDC 0121-4827-05
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cigna of CA HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.15

Service Code	NDC 0406-8556-05
Hospital Charge Code	1734061
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

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 0904-6678-40
Hospital Charge Code	1734061
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 0904-6678-40
Hospital Charge Code	1734061
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: 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 Beech St/Commercial/PHCS	$0.08

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.42

Service Code	NDC 0121-4827-05
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.06
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	$0.64
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 Beech St/Commercial/PHCS	$1.06

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.42

Service Code	NDC 0121-4827-40
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cigna of CA HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.42

Service Code	NDC 0121-4827-40
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Cash Price	$0.64
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: 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 Beech St/Commercial/PHCS	$1.06

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$1.66

Service Code	NDC 66689-401-50
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.00
Rate for Payer: Aetna of CA Government/Medicare	$1.00
Rate for Payer: Cash Price	$0.75
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

OXYCODONE 5 MG/5 ML ORAL SOLUTION [10813]

Facility

$0.10

Service Code	NDC 9999-9108-13
Hospital Charge Code	1730169
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

Know your out-of-pocket cost for care.

All Charges