Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]

Facility

$8.56

Service Code	NDC 0406-9125-76
Hospital Charge Code	1737052
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.85
Rate for Payer: Cash Price	$3.85
Rate for Payer: Cigna of CA HMO/PPO	$6.85
Rate for Payer: Health Smart Auto/Commercial	$5.14
Rate for Payer: LLUH Dept of Risk Management WC	$4.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.42

FENTANYL 25 MCG/HR TRANSDERMAL PATCH [27905]

Facility

$8.56

Service Code	NDC 0406-9125-76
Hospital Charge Code	1737052
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.14
Rate for Payer: Aetna of CA Government/Medicare	$5.14
Rate for Payer: Cash Price	$3.85
Rate for Payer: Health Smart Auto/Commercial	$5.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.14
Rate for Payer: LLUH Dept of Risk Management WC	$4.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.42

FENTANYL 400 MCG LOZENGE ON A HANDLE [27914]

Facility

$18.53

Service Code	NDC 0406-9204-30
Hospital Charge Code	1730147
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$14.82
Rate for Payer: Cash Price	$8.34
Rate for Payer: Cigna of CA HMO/PPO	$14.82
Rate for Payer: Health Smart Auto/Commercial	$11.12
Rate for Payer: LLUH Dept of Risk Management WC	$10.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.90

FENTANYL 400 MCG LOZENGE ON A HANDLE [27914]

Facility

$18.53

Service Code	NDC 0406-9204-30
Hospital Charge Code	1730147
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$13.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.12
Rate for Payer: Aetna of CA Government/Medicare	$11.12
Rate for Payer: Cash Price	$8.34
Rate for Payer: Health Smart Auto/Commercial	$11.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.12
Rate for Payer: LLUH Dept of Risk Management WC	$10.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.90

FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]

Facility

$15.20

Service Code	NDC 0406-9150-76
Hospital Charge Code	1737053
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$11.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.12
Rate for Payer: Aetna of CA Government/Medicare	$9.12
Rate for Payer: Cash Price	$6.84
Rate for Payer: Health Smart Auto/Commercial	$9.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.40

FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]

Facility

$15.20

Service Code	NDC 0406-9050-76
Hospital Charge Code	1737053
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$11.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.12
Rate for Payer: Aetna of CA Government/Medicare	$9.12
Rate for Payer: Cash Price	$6.84
Rate for Payer: Health Smart Auto/Commercial	$9.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.40

FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]

Facility

$15.20

Service Code	NDC 0406-9050-76
Hospital Charge Code	1737053
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$12.16
Rate for Payer: Cash Price	$6.84
Rate for Payer: Cigna of CA HMO/PPO	$12.16
Rate for Payer: Health Smart Auto/Commercial	$9.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.40

FENTANYL 50 MCG/HR TRANSDERMAL PATCH [27906]

Facility

$15.20

Service Code	NDC 0406-9150-76
Hospital Charge Code	1737053
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$12.16
Rate for Payer: Cash Price	$6.84
Rate for Payer: Cigna of CA HMO/PPO	$12.16
Rate for Payer: Health Smart Auto/Commercial	$9.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.40

FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]

Facility

$24.02

Service Code	NDC 0406-9175-76
Hospital Charge Code	1737054
Hospital Revenue Code	259
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$18.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.41
Rate for Payer: Aetna of CA Government/Medicare	$14.41
Rate for Payer: Cash Price	$10.81
Rate for Payer: Health Smart Auto/Commercial	$14.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.41
Rate for Payer: LLUH Dept of Risk Management WC	$13.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.02

FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]

Facility

$24.02

Service Code	NDC 0378-9123-16
Hospital Charge Code	1737054
Hospital Revenue Code	259
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$18.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.41
Rate for Payer: Aetna of CA Government/Medicare	$14.41
Rate for Payer: Cash Price	$10.81
Rate for Payer: Health Smart Auto/Commercial	$14.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.41
Rate for Payer: LLUH Dept of Risk Management WC	$13.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.02

FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]

Facility

$24.02

Service Code	NDC 0378-9123-98
Hospital Charge Code	1737054
Hospital Revenue Code	259
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$18.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.41
Rate for Payer: Aetna of CA Government/Medicare	$14.41
Rate for Payer: Cash Price	$10.81
Rate for Payer: Health Smart Auto/Commercial	$14.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.41
Rate for Payer: LLUH Dept of Risk Management WC	$13.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.02

FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]

Facility

$24.02

Service Code	NDC 0378-9123-16
Hospital Charge Code	1737054
Hospital Revenue Code	259
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$10.81
Rate for Payer: Cigna of CA HMO/PPO	$19.22
Rate for Payer: Health Smart Auto/Commercial	$14.41
Rate for Payer: LLUH Dept of Risk Management WC	$13.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.02

FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]

Facility

$24.02

Service Code	NDC 0378-9123-98
Hospital Charge Code	1737054
Hospital Revenue Code	259
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$10.81
Rate for Payer: Cigna of CA HMO/PPO	$19.22
Rate for Payer: Health Smart Auto/Commercial	$14.41
Rate for Payer: LLUH Dept of Risk Management WC	$13.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.02

FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]

Facility

$24.02

Service Code	NDC 0406-9175-76
Hospital Charge Code	1737054
Hospital Revenue Code	259
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$10.81
Rate for Payer: Cigna of CA HMO/PPO	$19.22
Rate for Payer: Health Smart Auto/Commercial	$14.41
Rate for Payer: LLUH Dept of Risk Management WC	$13.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.02

FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX ADULT [4081452]

Facility

$0.18

Service Code	NDC 71286-2081-1
Hospital Charge Code	NDG2569
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

FENTANYL-BUPIVACAINE 2 MCG/ML-0.0625% EPIDURAL PREMIX ADULT [4081452]

Facility

$0.18

Service Code	NDC 71286-2081-1
Hospital Charge Code	NDG2569
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	$0.08
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 Beech St/Commercial/PHCS	$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	NDG2569
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	$0.08
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 Beech St/Commercial/PHCS	$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	NDG2569
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

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

Facility

$0.18

Service Code	NDC 70004-244-40
Hospital Charge Code	NDG2569
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	$0.08
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 Beech St/Commercial/PHCS	$0.14

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

Facility

$0.18

Service Code	NDC 70004-244-40
Hospital Charge Code	NDG2569
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

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

Facility

$1.43

Service Code	CPT J3010
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.07
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	$0.64
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 Beech St/Commercial/PHCS	$1.07

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

Facility

$1.43

Service Code	CPT J3010
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.07

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

Facility

$0.29

Service Code	CPT J3010
Hospital Charge Code	NDG117731
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.22
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	$0.13
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 Beech St/Commercial/PHCS	$0.22

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

Facility

$0.29

Service Code	CPT J3010
Hospital Charge Code	NDG117731
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.22

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

Facility

$0.32

Service Code	CPT J3010
Hospital Charge Code	NDG408121190
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
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	$0.14
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 Beech St/Commercial/PHCS	$0.24

Know your out-of-pocket cost for care.

All Charges