Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FENOFIBRATE 160 MG TABLET [28252]

Facility

$2.87

Service Code	NDC 60687-864-21
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: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

FENOFIBRATE 160 MG TABLET [28252]

Facility

$0.19

Service Code	NDC 42858-660-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.14

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: Aetna of CA EPO/HMO/POS/PPO	$1.72
Rate for Payer: Aetna of CA Government/Medicare	$1.72
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$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

$0.19

Service Code	NDC 42858-660-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
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	$0.15
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

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.27

Service Code	NDC 27241-116-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.27

Service Code	NDC 27241-116-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.18

Service Code	NDC 42858-454-45
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

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.26

Service Code	NDC 63304-900-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.18

Service Code	NDC 42858-454-45
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

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.26

Service Code	NDC 63304-900-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]

Facility

$33.07

Service Code	NDC 0406-9100-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.19
Max. Negotiated Rate	$26.46
Rate for Payer: Cash Price	$18.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.46
Rate for Payer: Health Smart Auto/Commercial	$19.84
Rate for Payer: LLUH Dept of Risk Management WC	$18.19
Rate for Payer: Multiplan Commercial	$24.80

FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]

Facility

$33.07

Service Code	NDC 0406-9100-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.19
Max. Negotiated Rate	$26.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.84
Rate for Payer: Aetna of CA Government/Medicare	$19.84
Rate for Payer: Cash Price	$18.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.46
Rate for Payer: Health Smart Auto/Commercial	$19.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.84
Rate for Payer: LLUH Dept of Risk Management WC	$18.19
Rate for Payer: Multiplan Commercial	$24.80

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 47781-423-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Cash Price	$10.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.59
Rate for Payer: Health Smart Auto/Commercial	$11.69
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$5.28

Service Code	NDC 50742-549-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$4.22
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Commercial	$3.96

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 47781-423-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Cash Price	$10.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.59
Rate for Payer: Health Smart Auto/Commercial	$11.69
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$5.28

Service Code	NDC 50742-549-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$4.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.17
Rate for Payer: Aetna of CA Government/Medicare	$3.17
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.17
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Commercial	$3.96

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$5.28

Service Code	NDC 50742-549-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$4.22
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Commercial	$3.96

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 0406-9112-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.69
Rate for Payer: Aetna of CA Government/Medicare	$11.69
Rate for Payer: Cash Price	$10.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.59
Rate for Payer: Health Smart Auto/Commercial	$11.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.69
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$5.28

Service Code	NDC 50742-549-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.90
Max. Negotiated Rate	$4.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.17
Rate for Payer: Aetna of CA Government/Medicare	$3.17
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.17
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Commercial	$3.96

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 47781-423-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.69
Rate for Payer: Aetna of CA Government/Medicare	$11.69
Rate for Payer: Cash Price	$10.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.59
Rate for Payer: Health Smart Auto/Commercial	$11.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.69
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 47781-423-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.69
Rate for Payer: Aetna of CA Government/Medicare	$11.69
Rate for Payer: Cash Price	$10.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.59
Rate for Payer: Health Smart Auto/Commercial	$11.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.69
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 0406-9112-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Cash Price	$10.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.59
Rate for Payer: Health Smart Auto/Commercial	$11.69
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]

Facility

$8.56

Service Code	NDC 0378-9121-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.85
Rate for Payer: Cash Price	$4.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.85
Rate for Payer: Health Smart Auto/Commercial	$5.14
Rate for Payer: LLUH Dept of Risk Management WC	$4.71
Rate for Payer: Multiplan Commercial	$6.42

Know your out-of-pocket cost for care.

All Charges