Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FENOFIBRATE 160 MG TABLET [28252]

Facility

$2.88

Service Code	NDC 42858-660-45
Hospital Charge Code	1712496
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.30
Rate for Payer: Cash Price	$1.30
Rate for Payer: Cigna of CA HMO/PPO	$2.30
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.16

FENOFIBRATE 160 MG TABLET [28252]

Facility

$3.51

Service Code	NDC 68084-328-11
Hospital Charge Code	1712496
Hospital Revenue Code	259
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$2.81
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna of CA HMO/PPO	$2.81
Rate for Payer: Health Smart Auto/Commercial	$2.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.63

FENOFIBRATE 160 MG TABLET [28252]

Facility

$3.51

Service Code	NDC 68084-328-11
Hospital Charge Code	1712496
Hospital Revenue Code	259
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.11
Rate for Payer: Aetna of CA Government/Medicare	$2.11
Rate for Payer: Cash Price	$1.58
Rate for Payer: Health Smart Auto/Commercial	$2.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.63

FENOFIBRATE 160 MG TABLET [28252]

Facility

$2.88

Service Code	NDC 42858-660-45
Hospital Charge Code	1712496
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.73
Rate for Payer: Aetna of CA Government/Medicare	$1.73
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.16

FENOFIBRATE 160 MG TABLET [28252]

Facility

$3.51

Service Code	NDC 68084-328-21
Hospital Charge Code	1712496
Hospital Revenue Code	259
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.11
Rate for Payer: Aetna of CA Government/Medicare	$2.11
Rate for Payer: Cash Price	$1.58
Rate for Payer: Health Smart Auto/Commercial	$2.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.63

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.26

Service Code	NDC 63304-900-90
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$1.30

Service Code	NDC 68084-827-95
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.26

Service Code	NDC 63304-900-90
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
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	$0.12
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 Beech St/Commercial/PHCS	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.82

Service Code	NDC 42858-454-45
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.62
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	$0.37
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 Beech St/Commercial/PHCS	$0.62

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.27

Service Code	NDC 27241-116-03
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.20
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	$0.12
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 Beech St/Commercial/PHCS	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.82

Service Code	NDC 42858-454-45
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.62

FENOFIBRATE 54 MG TABLET [31336]

Facility

$0.27

Service Code	NDC 27241-116-03
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

FENOFIBRATE 54 MG TABLET [31336]

Facility

$1.30

Service Code	NDC 68084-827-95
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

FENOFIBRATE 54 MG TABLET [31336]

Facility

$1.30

Service Code	NDC 68084-827-25
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

FENOFIBRATE 54 MG TABLET [31336]

Facility

$1.30

Service Code	NDC 68084-827-25
Hospital Charge Code	1712510
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

FENOLDOPAM 10 MG/ML INTRAVENOUS SOLUTION [22133]

Facility

$597.48

Service Code	NDC 0409-3373-01
Hospital Charge Code	1759555
Hospital Revenue Code	250
Min. Negotiated Rate	$328.61
Max. Negotiated Rate	$448.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$358.49
Rate for Payer: Aetna of CA Government/Medicare	$358.49
Rate for Payer: Cash Price	$268.87
Rate for Payer: Health Smart Auto/Commercial	$358.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$358.49
Rate for Payer: LLUH Dept of Risk Management WC	$328.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$448.11

FENOLDOPAM 10 MG/ML INTRAVENOUS SOLUTION [22133]

Facility

$597.48

Service Code	NDC 0409-3373-01
Hospital Charge Code	1759555
Hospital Revenue Code	250
Min. Negotiated Rate	$328.61
Max. Negotiated Rate	$477.98
Rate for Payer: Cash Price	$268.87
Rate for Payer: Cigna of CA HMO/PPO	$477.98
Rate for Payer: Health Smart Auto/Commercial	$358.49
Rate for Payer: LLUH Dept of Risk Management WC	$328.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$448.11

FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]

Facility

$33.07

Service Code	NDC 0406-9100-76
Hospital Charge Code	1737055
Hospital Revenue Code	259
Min. Negotiated Rate	$18.19
Max. Negotiated Rate	$26.46
Rate for Payer: Cash Price	$14.88
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$24.80

FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]

Facility

$33.07

Service Code	NDC 0406-9100-76
Hospital Charge Code	1737055
Hospital Revenue Code	259
Min. Negotiated Rate	$18.19
Max. Negotiated Rate	$24.80
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	$14.88
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 Beech St/Commercial/PHCS	$24.80

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 0406-9112-76
Hospital Charge Code	1730786
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.59
Rate for Payer: Cash Price	$8.77
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$14.62

FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]

Facility

$19.49

Service Code	NDC 0406-9112-76
Hospital Charge Code	1730786
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$14.62
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	$8.77
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 Beech St/Commercial/PHCS	$14.62

FENTANYL 1,600 MCG LOZENGE ON A HANDLE [27918]

Facility

$43.11

Service Code	NDC 0406-9216-30
Hospital Charge Code	1730151
Hospital Revenue Code	259
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$34.49
Rate for Payer: Cash Price	$19.40
Rate for Payer: Cigna of CA HMO/PPO	$34.49
Rate for Payer: Health Smart Auto/Commercial	$25.87
Rate for Payer: LLUH Dept of Risk Management WC	$23.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.33

FENTANYL 1,600 MCG LOZENGE ON A HANDLE [27918]

Facility

$43.11

Service Code	NDC 0406-9216-30
Hospital Charge Code	1730151
Hospital Revenue Code	259
Min. Negotiated Rate	$23.71
Max. Negotiated Rate	$32.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.87
Rate for Payer: Aetna of CA Government/Medicare	$25.87
Rate for Payer: Cash Price	$19.40
Rate for Payer: Health Smart Auto/Commercial	$25.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.87
Rate for Payer: LLUH Dept of Risk Management WC	$23.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.33

FENTANYL 200 MCG LOZENGE ON A HANDLE [27913]

Facility

$14.62

Service Code	NDC 0406-9202-30
Hospital Charge Code	1730148
Hospital Revenue Code	259
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$10.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.77
Rate for Payer: Aetna of CA Government/Medicare	$8.77
Rate for Payer: Cash Price	$6.58
Rate for Payer: Health Smart Auto/Commercial	$8.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.77
Rate for Payer: LLUH Dept of Risk Management WC	$8.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.96

FENTANYL 200 MCG LOZENGE ON A HANDLE [27913]

Facility

$14.62

Service Code	NDC 0406-9202-30
Hospital Charge Code	1730148
Hospital Revenue Code	259
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$11.70
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cigna of CA HMO/PPO	$11.70
Rate for Payer: Health Smart Auto/Commercial	$8.77
Rate for Payer: LLUH Dept of Risk Management WC	$8.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.96

Know your out-of-pocket cost for care.

All Charges