Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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

$1.66

Service Code	NDC 66689-401-01
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

$0.15

Service Code	NDC 0406-8556-05
Hospital Charge Code	1734061
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 0406-0552-23
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.24
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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.24

Service Code	NDC 0406-0552-01
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
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	$0.11
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 Beech St/Commercial/PHCS	$0.18

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-11
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.25
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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.10

Service Code	NDC 10702-018-50
Hospital Charge Code	1730142
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 TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-01
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.25
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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-11
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 0406-0552-62
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 42858-001-10
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.24
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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 9940-8204-83
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.25
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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 0406-0552-62
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.25
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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 9940-8204-83
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.24

Service Code	NDC 0406-0552-01
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.18

OXYCODONE 5 MG TABLET [10814]

Facility

$0.55

Service Code	NDC 68084-354-01
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.10

Service Code	NDC 10702-018-50
Hospital Charge Code	1730142
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 TABLET [10814]

Facility

$0.54

Service Code	NDC 0406-0552-23
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

OXYCODONE 5 MG TABLET [10814]

Facility

$0.54

Service Code	NDC 42858-001-10
Hospital Charge Code	1730142
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

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

Facility

$2.06

Service Code	NDC 68084-710-01
Hospital Charge Code	1730174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.54
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	$0.93
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 Beech St/Commercial/PHCS	$1.54

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

Facility

$2.27

Service Code	NDC 0406-0523-23
Hospital Charge Code	1730174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cigna of CA HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

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

Facility

$2.27

Service Code	NDC 0406-0523-62
Hospital Charge Code	1730174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

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

Facility

$2.16

Service Code	NDC 68308-480-47
Hospital Charge Code	1730174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.30
Rate for Payer: Aetna of CA Government/Medicare	$1.30
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.30
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.62

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

Facility

$2.06

Service Code	NDC 68084-710-11
Hospital Charge Code	1730174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.65
Rate for Payer: Cash Price	$0.93
Rate for Payer: Cigna of CA HMO/PPO	$1.65
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.54

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

Facility

$0.59

Service Code	NDC 0406-0523-01
Hospital Charge Code	1730174
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.44

Know your out-of-pocket cost for care.

All Charges