Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR [96973]

Facility

$11.60

Service Code	NDC 0069-0242-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$9.28
Rate for Payer: Cash Price	$6.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.28
Rate for Payer: Health Smart Auto/Commercial	$6.96
Rate for Payer: LLUH Dept of Risk Management WC	$6.38
Rate for Payer: Multiplan Commercial	$8.70

FEXOFENADINE 180 MG TABLET [25425]

Facility

$0.69

Service Code	NDC 41167-4120-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

FEXOFENADINE 180 MG TABLET [25425]

Facility

$0.69

Service Code	NDC 41167-4120-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

FIBRINOGEN-THROMBIN 9.5 CM X 4.8 CM TOPICAL PATCH [105430]

Facility

$843.79

Service Code	NDC 0338-8701-00
Min. Negotiated Rate	$464.08
Max. Negotiated Rate	$675.03
Rate for Payer: Cash Price	$464.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$675.03
Rate for Payer: Health Smart Auto/Commercial	$506.27
Rate for Payer: LLUH Dept of Risk Management WC	$464.08
Rate for Payer: Multiplan Commercial	$632.84

FIBRINOGEN-THROMBIN 9.5 CM X 4.8 CM TOPICAL PATCH [105430]

Facility

$843.79

Service Code	NDC 0338-8701-00
Min. Negotiated Rate	$464.08
Max. Negotiated Rate	$675.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$506.27
Rate for Payer: Aetna of CA Government/Medicare	$506.27
Rate for Payer: Cash Price	$464.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$675.03
Rate for Payer: Health Smart Auto/Commercial	$506.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$506.27
Rate for Payer: LLUH Dept of Risk Management WC	$464.08
Rate for Payer: Multiplan Commercial	$632.84

FIDAXOMICIN 200 MG TABLET [153338]

Facility

$312.30

Service Code	NDC 52015-080-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$171.76
Max. Negotiated Rate	$249.84
Rate for Payer: Cash Price	$171.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$249.84
Rate for Payer: Health Smart Auto/Commercial	$187.38
Rate for Payer: LLUH Dept of Risk Management WC	$171.76
Rate for Payer: Multiplan Commercial	$234.22

FIDAXOMICIN 200 MG TABLET [153338]

Facility

$312.30

Service Code	NDC 52015-080-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$171.76
Max. Negotiated Rate	$249.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$187.38
Rate for Payer: Aetna of CA Government/Medicare	$187.38
Rate for Payer: Cash Price	$171.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$249.84
Rate for Payer: Health Smart Auto/Commercial	$187.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$187.38
Rate for Payer: LLUH Dept of Risk Management WC	$171.76
Rate for Payer: Multiplan Commercial	$234.22

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

$45.93

Service Code	NDC 52015-700-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.26
Max. Negotiated Rate	$36.74
Rate for Payer: Cash Price	$25.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.74
Rate for Payer: Health Smart Auto/Commercial	$27.56
Rate for Payer: LLUH Dept of Risk Management WC	$25.26
Rate for Payer: Multiplan Commercial	$34.45

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

$45.93

Service Code	NDC 52015-700-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.26
Max. Negotiated Rate	$36.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.56
Rate for Payer: Aetna of CA Government/Medicare	$27.56
Rate for Payer: Cash Price	$25.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.74
Rate for Payer: Health Smart Auto/Commercial	$27.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.56
Rate for Payer: LLUH Dept of Risk Management WC	$25.26
Rate for Payer: Multiplan Commercial	$34.45

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

$45.93

Service Code	NDC 52015-700-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.26
Max. Negotiated Rate	$36.74
Rate for Payer: Cash Price	$25.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.74
Rate for Payer: Health Smart Auto/Commercial	$27.56
Rate for Payer: LLUH Dept of Risk Management WC	$25.26
Rate for Payer: Multiplan Commercial	$34.45

FIDAXOMICIN 40 MG/ML ORAL SUSPENSION [229582]

Facility

$45.93

Service Code	NDC 52015-700-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$25.26
Max. Negotiated Rate	$36.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.56
Rate for Payer: Aetna of CA Government/Medicare	$27.56
Rate for Payer: Cash Price	$25.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.74
Rate for Payer: Health Smart Auto/Commercial	$27.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.56
Rate for Payer: LLUH Dept of Risk Management WC	$25.26
Rate for Payer: Multiplan Commercial	$34.45

FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [233796]

Facility

$381.60

Service Code	HCPCS Q5125
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$209.88
Max. Negotiated Rate	$305.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$228.96
Rate for Payer: Aetna of CA Government/Medicare	$228.96
Rate for Payer: Cash Price	$209.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$305.28
Rate for Payer: Health Smart Auto/Commercial	$228.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$228.96
Rate for Payer: LLUH Dept of Risk Management WC	$209.88
Rate for Payer: Multiplan Commercial	$286.20

FILGRASTIM-AYOW 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE [233796]

Facility

$381.60

Service Code	HCPCS Q5125
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$209.88
Max. Negotiated Rate	$305.28
Rate for Payer: Cash Price	$209.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$305.28
Rate for Payer: Health Smart Auto/Commercial	$228.96
Rate for Payer: LLUH Dept of Risk Management WC	$209.88
Rate for Payer: Multiplan Commercial	$286.20

FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [233797]

Facility

$381.60

Service Code	HCPCS Q5125
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$209.88
Max. Negotiated Rate	$305.28
Rate for Payer: Cash Price	$209.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$305.28
Rate for Payer: Health Smart Auto/Commercial	$228.96
Rate for Payer: LLUH Dept of Risk Management WC	$209.88
Rate for Payer: Multiplan Commercial	$286.20

FILGRASTIM-AYOW 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [233797]

Facility

$381.60

Service Code	HCPCS Q5125
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$209.88
Max. Negotiated Rate	$305.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$228.96
Rate for Payer: Aetna of CA Government/Medicare	$228.96
Rate for Payer: Cash Price	$209.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$305.28
Rate for Payer: Health Smart Auto/Commercial	$228.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$228.96
Rate for Payer: LLUH Dept of Risk Management WC	$209.88
Rate for Payer: Multiplan Commercial	$286.20

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]

Facility

$658.47

Service Code	HCPCS Q5101
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$526.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$395.08
Rate for Payer: Aetna of CA Government/Medicare	$395.08
Rate for Payer: Cash Price	$362.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$526.78
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Commercial	$493.85

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE [211102]

Facility

$658.47

Service Code	HCPCS Q5101
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$526.78
Rate for Payer: Cash Price	$362.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$526.78
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Commercial	$493.85

FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [211101]

Facility

$658.47

Service Code	HCPCS Q5101
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$526.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$395.08
Rate for Payer: Aetna of CA Government/Medicare	$395.08
Rate for Payer: Cash Price	$362.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$526.78
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Commercial	$493.85

FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [211101]

Facility

$658.47

Service Code	HCPCS Q5101
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$362.16
Max. Negotiated Rate	$526.78
Rate for Payer: Cash Price	$362.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$526.78
Rate for Payer: Health Smart Auto/Commercial	$395.08
Rate for Payer: LLUH Dept of Risk Management WC	$362.16
Rate for Payer: Multiplan Commercial	$493.85

FINASTERIDE 5 MG TABLET [10037]

Facility

$0.68

Service Code	HCPCS S0138
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.51
Rate for Payer: Multiplan Commercial	$0.81

FINASTERIDE 5 MG TABLET [10037]

Facility

$1.08

Service Code	HCPCS S0138
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81
Rate for Payer: Multiplan Commercial	$0.51

FINASTERIDE (PROSCAR) CRUSHED TABLET IN WATER [4081461]

Facility

$0.10

Service Code	HCPCS S0138
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

FINASTERIDE (PROSCAR) CRUSHED TABLET IN WATER [4081461]

Facility

$0.10

Service Code	HCPCS S0138
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

FLAVORX LIQUID [100560]

Facility

$0.12

Service Code	NDC 86067-00047
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

FLAVORX LIQUID [100560]

Facility

$0.12

Service Code	NDC 86067-00047
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

Know your out-of-pocket cost for care.

All Charges