Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.54

Service Code	NDC 0185-0415-60
Hospital Charge Code	1711720
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

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.73

Service Code	NDC 68084-708-95
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.32

Service Code	NDC 43547-289-50
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.70

Service Code	NDC 0904-6585-61
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.73

Service Code	NDC 68084-708-25
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.70

Service Code	NDC 0904-7214-61
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.70

Service Code	NDC 0904-6585-61
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.32

Service Code	NDC 43547-289-50
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.54

Service Code	NDC 0185-0415-60
Hospital Charge Code	1711720
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

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.70

Service Code	NDC 0904-7214-61
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.73

Service Code	NDC 68084-708-95
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]

Facility

$0.73

Service Code	NDC 68084-708-25
Hospital Charge Code	1711720
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.20

Service Code	NDC 64679-102-01
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.20

Service Code	NDC 64679-102-01
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.22

Service Code	NDC 68180-319-06
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.22

Service Code	NDC 68180-319-06
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.22

Service Code	NDC 68180-319-09
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$1.80

Service Code	NDC 50268-140-13
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$1.80

Service Code	NDC 50268-140-13
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$1.58

Service Code	NDC 0904-7084-04
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.71
Rate for Payer: Cigna of CA HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.18

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.22

Service Code	NDC 16729-443-10
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$1.80

Service Code	NDC 50268-140-11
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.22

Service Code	NDC 68180-319-09
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$1.80

Service Code	NDC 50268-140-11
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [36775]

Facility

$0.22

Service Code	NDC 16729-443-10
Hospital Charge Code	1712279
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

Know your out-of-pocket cost for care.

All Charges