Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FLUCONAZOLE 200 MG TABLET [10045]

Facility

$0.78

Service Code	NDC 70710-1140-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

FLUCONAZOLE 200 MG TABLET [10045]

Facility

$0.78

Service Code	NDC 70710-1140-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE (ISO) HIGH DOSE IVPB [4081121]

Facility

$0.08

Service Code	HCPCS J1450
Hospital Charge Code	901700025
Hospital Revenue Code	636
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	$0.05
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

FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE (ISO) HIGH DOSE IVPB [4081121]

Facility

$0.08

Service Code	HCPCS J1450
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.05
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

FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10050]

Facility

$0.04

Service Code	HCPCS J1450
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Multiplan Commercial	$0.06

FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [10050]

Facility

$0.04

Service Code	HCPCS J1450
Hospital Charge Code	901700025
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Multiplan Commercial	$0.06

FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]

Facility

$1.37

Service Code	NDC 57237-150-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$1.03

FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]

Facility

$0.96

Service Code	NDC 0049-3450-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]

Facility

$0.96

Service Code	NDC 0049-3450-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]

Facility

$2.02

Service Code	NDC 59762-5030-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.62
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]

Facility

$1.37

Service Code	NDC 57237-150-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$1.03

FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [14233]

Facility

$2.02

Service Code	NDC 59762-5030-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.62
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

FLUCONAZOLE 50 MG TABLET [10046]

Facility

$0.40

Service Code	NDC 62559-990-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

FLUCONAZOLE 50 MG TABLET [10046]

Facility

$0.40

Service Code	NDC 57237-003-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

FLUCONAZOLE 50 MG TABLET [10046]

Facility

$0.80

Service Code	NDC 68462-101-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

FLUCONAZOLE 50 MG TABLET [10046]

Facility

$0.40

Service Code	NDC 57237-003-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

FLUCONAZOLE 50 MG TABLET [10046]

Facility

$0.40

Service Code	NDC 62559-990-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

FLUCONAZOLE 50 MG TABLET [10046]

Facility

$0.80

Service Code	NDC 68462-101-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

FLUCYTOSINE 250 MG CAPSULE [10051]

Facility

$12.00

Service Code	NDC 59651-331-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$6.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.00

FLUCYTOSINE 250 MG CAPSULE [10051]

Facility

$36.00

Service Code	NDC 42794-009-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

FLUCYTOSINE 250 MG CAPSULE [10051]

Facility

$36.00

Service Code	NDC 42794-009-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

FLUCYTOSINE 250 MG CAPSULE [10051]

Facility

$12.00

Service Code	NDC 59651-331-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cash Price	$6.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.00

FLUCYTOSINE 500 MG CAPSULE [10052]

Facility

$24.00

Service Code	NDC 43386-770-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Cash Price	$13.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

FLUCYTOSINE 500 MG CAPSULE [10052]

Facility

$68.00

Service Code	NDC 42794-010-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$37.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Commercial	$51.00

FLUCYTOSINE 500 MG CAPSULE [10052]

Facility

$24.00

Service Code	NDC 59651-332-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Cash Price	$13.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

Know your out-of-pocket cost for care.

All Charges