Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]

Facility

$0.95

Service Code	NDC 70092-1269-37
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]

Facility

$0.95

Service Code	NDC 70092-1269-37
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.57
Rate for Payer: Aetna of CA Government/Medicare	$0.57
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]

Facility

$0.18

Service Code	NDC 70004-244-40
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX PEDS [117212]

Facility

$0.18

Service Code	NDC 71286-2081-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
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

FENTANYL (PF) 1,500 MCG/30 ML (50 MCG/ML) PCA INTRAVENOUS SOLUTION [121423]

Facility

$1.43

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.07

FENTANYL (PF) 1,500 MCG/30 ML (50 MCG/ML) PCA INTRAVENOUS SOLUTION [121423]

Facility

$1.43

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.07

FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [112496]

Facility

$0.43

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$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: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.24
Rate for Payer: Multiplan Commercial	$0.32

FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [112496]

Facility

$0.32

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$0.24

FENTANYL (PF) 2,750 MCG/55 ML (50 MCG/ML) INTRAVENOUS PCA SYRINGE [117731]

Facility

$0.29

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

FENTANYL (PF) 2,750 MCG/55 ML (50 MCG/ML) INTRAVENOUS PCA SYRINGE [117731]

Facility

$0.29

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

FENTANYL (PF) 500 MCG/50 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE [121190]

Facility

$0.32

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
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	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
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 Commercial	$0.24

FENTANYL (PF) 500 MCG/50 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE [121190]

Facility

$0.32

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.24

FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]

Facility

$1.27

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
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: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cash Price	$1.29
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cash Price	$0.93
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$1.75
Rate for Payer: Multiplan Commercial	$0.62
Rate for Payer: Multiplan Commercial	$1.26
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Commercial	$0.95
Rate for Payer: Multiplan Commercial	$0.51

FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [3037]

Facility

$0.63

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$1.29
Rate for Payer: Cash Price	$0.93
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.95
Rate for Payer: Multiplan Commercial	$1.75
Rate for Payer: Multiplan Commercial	$0.62
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Commercial	$1.26
Rate for Payer: Multiplan Commercial	$0.51

FENTANYL (PF) 50 MCG/ML INJECTION SYRINGE [114243]

Facility

$2.65

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$2.12
Rate for Payer: Cash Price	$1.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.12
Rate for Payer: Health Smart Auto/Commercial	$1.59
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Commercial	$1.99

FENTANYL (PF) 50 MCG/ML INJECTION SYRINGE [114243]

Facility

$2.65

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.59
Rate for Payer: Aetna of CA Government/Medicare	$1.59
Rate for Payer: Cash Price	$1.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.12
Rate for Payer: Health Smart Auto/Commercial	$1.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.59
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Commercial	$1.99

FENTANYL ROPIVACAINE (3200) 2 MCG/ML 0.15% 250 ML EPIDURAL [4080615]

Facility

$0.85

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.51
Rate for Payer: Aetna of CA Government/Medicare	$0.51
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.64

FENTANYL ROPIVACAINE (3200) 2 MCG/ML 0.15% 250 ML EPIDURAL [4080615]

Facility

$0.85

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.68
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.64

FENTANYL-ROPIVACAINE-NACL (PF) 2.5 MCG/ML-0.15% EPIDURAL [4081421]

Facility

$1.27

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.95

FENTANYL-ROPIVACAINE-NACL (PF) 2.5 MCG/ML-0.15% EPIDURAL [4081421]

Facility

$1.27

Service Code	HCPCS J3010
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.95

FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [203170]

Facility

$117.81

Service Code	HCPCS J1439
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$94.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.69
Rate for Payer: Aetna of CA Government/Medicare	$70.69
Rate for Payer: Cash Price	$64.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.25
Rate for Payer: Health Smart Auto/Commercial	$70.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.69
Rate for Payer: LLUH Dept of Risk Management WC	$64.80
Rate for Payer: Multiplan Commercial	$88.36

FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [203170]

Facility

$117.81

Service Code	HCPCS J1439
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$94.25
Rate for Payer: Cash Price	$64.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.25
Rate for Payer: Health Smart Auto/Commercial	$70.69
Rate for Payer: LLUH Dept of Risk Management WC	$64.80
Rate for Payer: Multiplan Commercial	$88.36

FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR [201459]

Facility

$1.82

Service Code	NDC 10481-0112-8
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$1.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.00
Rate for Payer: Multiplan Commercial	$1.36

FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR [201459]

Facility

$1.82

Service Code	NDC 10481-0112-8
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.09
Rate for Payer: Aetna of CA Government/Medicare	$1.09
Rate for Payer: Cash Price	$1.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.00
Rate for Payer: Multiplan Commercial	$1.36

FERRIC SUBSULFATE 259 MG/G TOPICAL SOLUTION [28357]

Facility

$2.46

Service Code	NDC 59365-6065-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.97
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.97
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

Know your out-of-pocket cost for care.

All Charges