Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

FERRIC SUBSULFATE 259 MG/G TOPICAL SOLUTION [28357]

Facility

$2.46

Service Code	NDC 59365-6065-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

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: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.48
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

FERROUS FUMARATE 324 MG (106 MG IRON) TABLET [3063]

Facility

$0.35

Service Code	NDC 6025818201
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

FERROUS FUMARATE 324 MG (106 MG IRON) TABLET [3063]

Facility

$0.35

Service Code	NDC 6025818201
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

FERROUS GLUCONATE 324 MG (37.5 MG IRON) TABLET [188092]

Facility

$0.04

Service Code	NDC 2055501900
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

FERROUS GLUCONATE 324 MG (37.5 MG IRON) TABLET [188092]

Facility

$0.04

Service Code	NDC 2055501900
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET [3066]

Facility

$0.11

Service Code	NDC 0574050811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET [3066]

Facility

$0.06

Service Code	NDC 0574050801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET [3066]

Facility

$0.11

Service Code	NDC 0574050811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET [3066]

Facility

$0.06

Service Code	NDC 0574050801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET. [4081929]

Facility

$0.11

Service Code	NDC 0574050811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET. [4081929]

Facility

$0.06

Service Code	NDC 0574050801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET. [4081929]

Facility

$0.11

Service Code	NDC 0574050811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET. [4081929]

Facility

$0.06

Service Code	NDC 0574050801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]

Facility

$0.08

Service Code	NDC 7139974805
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]

Facility

$0.08

Service Code	NDC 7139974805
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL ELIXIR [215102]

Facility

$0.03

Service Code	NDC 5483800180
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL ELIXIR [215102]

Facility

$0.03

Service Code	NDC 5483800180
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL SOLUTION [3069]

Facility

$0.01

Service Code	NDC 5789670916
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL SOLUTION [3069]

Facility

$0.01

Service Code	NDC 5789670916
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [3071]

Facility

$0.82

Service Code	NDC 5852600557
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [3071]

Facility

$0.82

Service Code	NDC 5852600559
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [3071]

Facility

$0.82

Service Code	NDC 5852600557
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.62

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [3071]

Facility

$0.81

Service Code	NDC 0121053005
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Commercial	$0.61

Know your out-of-pocket cost for care.

All Charges