Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FEBUXOSTAT 40 MG TABLET [97133]

Facility

$0.60

Service Code	NDC 72205-028-30
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

FEBUXOSTAT 80 MG TABLET [97134]

Facility

$13.20

Service Code	NDC 64764-677-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

FEBUXOSTAT 80 MG TABLET [97134]

Facility

$13.20

Service Code	NDC 64764-677-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

FEDRATINIB 100 MG CAPSULE [225695]

Facility

$276.00

Service Code	NDC 59572-720-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$151.80
Max. Negotiated Rate	$220.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$165.60
Rate for Payer: Aetna of CA Government/Medicare	$165.60
Rate for Payer: Cash Price	$151.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$220.80
Rate for Payer: Health Smart Auto/Commercial	$165.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$165.60
Rate for Payer: LLUH Dept of Risk Management WC	$151.80
Rate for Payer: Multiplan Commercial	$207.00

FEDRATINIB 100 MG CAPSULE [225695]

Facility

$276.00

Service Code	NDC 59572-720-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$151.80
Max. Negotiated Rate	$220.80
Rate for Payer: Cash Price	$151.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$220.80
Rate for Payer: Health Smart Auto/Commercial	$165.60
Rate for Payer: LLUH Dept of Risk Management WC	$151.80
Rate for Payer: Multiplan Commercial	$207.00

FELBAMATE 400 MG TABLET [10024]

Facility

$18.52

Service Code	NDC 0037-0430-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$14.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.11
Rate for Payer: Aetna of CA Government/Medicare	$11.11
Rate for Payer: Cash Price	$10.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.82
Rate for Payer: Health Smart Auto/Commercial	$11.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.11
Rate for Payer: LLUH Dept of Risk Management WC	$10.19
Rate for Payer: Multiplan Commercial	$13.89

FELBAMATE 400 MG TABLET [10024]

Facility

$1.67

Service Code	NDC 72578-056-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.25

FELBAMATE 400 MG TABLET [10024]

Facility

$1.67

Service Code	NDC 72578-056-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
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	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
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	$0.92
Rate for Payer: Multiplan Commercial	$1.25

FELBAMATE 400 MG TABLET [10024]

Facility

$2.88

Service Code	NDC 65162-734-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.30
Rate for Payer: Cash Price	$1.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.30
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Commercial	$2.16

FELBAMATE 400 MG TABLET [10024]

Facility

$2.88

Service Code	NDC 65162-734-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.73
Rate for Payer: Aetna of CA Government/Medicare	$1.73
Rate for Payer: Cash Price	$1.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.30
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Commercial	$2.16

FELBAMATE 400 MG TABLET [10024]

Facility

$18.52

Service Code	NDC 0037-0430-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$14.82
Rate for Payer: Cash Price	$10.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.82
Rate for Payer: Health Smart Auto/Commercial	$11.11
Rate for Payer: LLUH Dept of Risk Management WC	$10.19
Rate for Payer: Multiplan Commercial	$13.89

FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]

Facility

$2.57

Service Code	NDC 51525-0442-8
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.93

FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]

Facility

$2.57

Service Code	NDC 51525-0442-8
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.06
Rate for Payer: Cash Price	$1.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.93

FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]

Facility

$1.04

Service Code	NDC 65162-686-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Commercial	$0.78

FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]

Facility

$1.04

Service Code	NDC 65162-686-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Commercial	$0.78

FELBAMATE 600 MG TABLET [10025]

Facility

$1.30

Service Code	NDC 62559-731-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

FELBAMATE 600 MG TABLET [10025]

Facility

$1.30

Service Code	NDC 62559-731-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

FELODIPINE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [27491]

Facility

$2.34

Service Code	NDC 53489-370-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.75

FELODIPINE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [27491]

Facility

$2.34

Service Code	NDC 53489-370-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.75

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.65

Service Code	NDC 57237-108-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.18

Service Code	NDC 68462-233-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.18

Service Code	NDC 68462-233-01
Hospital Charge Code	901700029
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	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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 Commercial	$0.14

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.65

Service Code	NDC 57237-108-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

FENOFIBRATE 160 MG TABLET [28252]

Facility

$2.87

Service Code	NDC 60687-864-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.30
Rate for Payer: Cash Price	$1.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.30
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Commercial	$2.15

FENOFIBRATE 160 MG TABLET [28252]

Facility

$0.47

Service Code	NDC 27241-117-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

Know your out-of-pocket cost for care.

All Charges