Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]

Facility

$4.20

Service Code	HCPCS J1808
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Cash Price	$4.22
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$4.60
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: LLUH Dept of Risk Management WC	$4.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15
Rate for Payer: Multiplan Commercial	$2.40
Rate for Payer: Multiplan Commercial	$5.75

FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]

Facility

$3.20

Service Code	HCPCS J1808
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.60
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$1.92
Rate for Payer: Aetna of CA Government/Medicare	$4.60
Rate for Payer: Cash Price	$4.22
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$4.60
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$4.22
Rate for Payer: Multiplan Commercial	$3.15
Rate for Payer: Multiplan Commercial	$2.40
Rate for Payer: Multiplan Commercial	$5.75

FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]

Facility

$0.51

Service Code	NDC 9994-0802-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]

Facility

$0.51

Service Code	NDC 9994-0802-76
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]

Facility

$788.00

Service Code	HCPCS J1451
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$433.40
Max. Negotiated Rate	$630.40
Rate for Payer: Cash Price	$433.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$630.40
Rate for Payer: Health Smart Auto/Commercial	$472.80
Rate for Payer: LLUH Dept of Risk Management WC	$433.40
Rate for Payer: Multiplan Commercial	$591.00

FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]

Facility

$788.00

Service Code	HCPCS J1451
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$433.40
Max. Negotiated Rate	$630.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$472.80
Rate for Payer: Aetna of CA Government/Medicare	$472.80
Rate for Payer: Cash Price	$433.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$630.40
Rate for Payer: Health Smart Auto/Commercial	$472.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$472.80
Rate for Payer: LLUH Dept of Risk Management WC	$433.40
Rate for Payer: Multiplan Commercial	$591.00

FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]

Facility

$87.15

Service Code	HCPCS J1652
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.93
Max. Negotiated Rate	$69.72
Rate for Payer: Cash Price	$47.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.72
Rate for Payer: Health Smart Auto/Commercial	$52.29
Rate for Payer: LLUH Dept of Risk Management WC	$47.93
Rate for Payer: Multiplan Commercial	$65.36

FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]

Facility

$87.15

Service Code	HCPCS J1652
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.93
Max. Negotiated Rate	$69.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.29
Rate for Payer: Aetna of CA Government/Medicare	$52.29
Rate for Payer: Cash Price	$47.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.72
Rate for Payer: Health Smart Auto/Commercial	$52.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.29
Rate for Payer: LLUH Dept of Risk Management WC	$47.93
Rate for Payer: Multiplan Commercial	$65.36

FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]

Facility

$59.66

Service Code	HCPCS J1652
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.81
Max. Negotiated Rate	$47.73
Rate for Payer: Cash Price	$32.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.73
Rate for Payer: Health Smart Auto/Commercial	$35.80
Rate for Payer: LLUH Dept of Risk Management WC	$32.81
Rate for Payer: Multiplan Commercial	$44.74

FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]

Facility

$59.66

Service Code	HCPCS J1652
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.81
Max. Negotiated Rate	$47.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.80
Rate for Payer: Aetna of CA Government/Medicare	$35.80
Rate for Payer: Cash Price	$32.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.73
Rate for Payer: Health Smart Auto/Commercial	$35.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.80
Rate for Payer: LLUH Dept of Risk Management WC	$32.81
Rate for Payer: Multiplan Commercial	$44.74

FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]

Facility

$110.60

Service Code	HCPCS J1652
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$60.83
Max. Negotiated Rate	$88.48
Rate for Payer: Cash Price	$60.83
Rate for Payer: Cash Price	$59.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.48
Rate for Payer: Health Smart Auto/Commercial	$66.36
Rate for Payer: Health Smart Auto/Commercial	$65.18
Rate for Payer: LLUH Dept of Risk Management WC	$59.75
Rate for Payer: LLUH Dept of Risk Management WC	$60.83
Rate for Payer: Multiplan Commercial	$81.48
Rate for Payer: Multiplan Commercial	$82.95

FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]

Facility

$108.64

Service Code	HCPCS J1652
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$59.75
Max. Negotiated Rate	$86.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$65.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.36
Rate for Payer: Aetna of CA Government/Medicare	$66.36
Rate for Payer: Aetna of CA Government/Medicare	$65.18
Rate for Payer: Cash Price	$59.75
Rate for Payer: Cash Price	$60.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.48
Rate for Payer: Health Smart Auto/Commercial	$65.18
Rate for Payer: Health Smart Auto/Commercial	$66.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$65.18
Rate for Payer: LLUH Dept of Risk Management WC	$59.75
Rate for Payer: LLUH Dept of Risk Management WC	$60.83
Rate for Payer: Multiplan Commercial	$82.95
Rate for Payer: Multiplan Commercial	$81.48

FOOD SUPPLEMNT,LACTO-REDUCE 0.05 GRAM-1.2 KCAL/ML LIQUID FOR TUBE FEED [216461]

Facility

$0.01

Service Code	NDC 4390018480
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

FOOD SUPPLEMNT,LACTO-REDUCE 0.05 GRAM-1.2 KCAL/ML LIQUID FOR TUBE FEED [216461]

Facility

$0.01

Service Code	NDC 4390018480
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

FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]

Facility

$12.30

Service Code	NDC 49502-605-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$9.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.38
Rate for Payer: Aetna of CA Government/Medicare	$7.38
Rate for Payer: Cash Price	$6.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.84
Rate for Payer: Health Smart Auto/Commercial	$7.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.38
Rate for Payer: LLUH Dept of Risk Management WC	$6.76
Rate for Payer: Multiplan Commercial	$9.22

FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]

Facility

$12.30

Service Code	NDC 49502-605-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$9.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.38
Rate for Payer: Aetna of CA Government/Medicare	$7.38
Rate for Payer: Cash Price	$6.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.84
Rate for Payer: Health Smart Auto/Commercial	$7.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.38
Rate for Payer: LLUH Dept of Risk Management WC	$6.76
Rate for Payer: Multiplan Commercial	$9.22

FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]

Facility

$12.30

Service Code	NDC 49502-605-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$9.84
Rate for Payer: Cash Price	$6.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.84
Rate for Payer: Health Smart Auto/Commercial	$7.38
Rate for Payer: LLUH Dept of Risk Management WC	$6.76
Rate for Payer: Multiplan Commercial	$9.22

FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]

Facility

$12.30

Service Code	NDC 49502-605-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$9.84
Rate for Payer: Cash Price	$6.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.84
Rate for Payer: Health Smart Auto/Commercial	$7.38
Rate for Payer: LLUH Dept of Risk Management WC	$6.76
Rate for Payer: Multiplan Commercial	$9.22

FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]

Facility

$30.00

Service Code	HCPCS J1453
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$59.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.16
Rate for Payer: Aetna of CA Government/Medicare	$20.16
Rate for Payer: Aetna of CA Government/Medicare	$30.24
Rate for Payer: Aetna of CA Government/Medicare	$59.17
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$18.48
Rate for Payer: Cash Price	$54.24
Rate for Payer: Cash Price	$16.50
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$26.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$78.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: Health Smart Auto/Commercial	$59.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$59.17
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: LLUH Dept of Risk Management WC	$18.48
Rate for Payer: LLUH Dept of Risk Management WC	$54.24
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: Multiplan Commercial	$73.97
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$22.50
Rate for Payer: Multiplan Commercial	$36.00
Rate for Payer: Multiplan Commercial	$25.20

FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]

Facility

$50.40

Service Code	HCPCS J1453
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$40.32
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$16.50
Rate for Payer: Cash Price	$54.24
Rate for Payer: Cash Price	$18.48
Rate for Payer: Cash Price	$26.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$78.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Health Smart Auto/Commercial	$20.16
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: Health Smart Auto/Commercial	$59.17
Rate for Payer: LLUH Dept of Risk Management WC	$54.24
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$18.48
Rate for Payer: Multiplan Commercial	$36.00
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$22.50
Rate for Payer: Multiplan Commercial	$73.97
Rate for Payer: Multiplan Commercial	$25.20

FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]

Facility

$2.27

Service Code	HCPCS J1455
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.22
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.22
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cash Price	$1.25
Rate for Payer: Cash Price	$1.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.63
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Commercial	$1.30
Rate for Payer: Multiplan Commercial	$1.53
Rate for Payer: Multiplan Commercial	$1.70

FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]

Facility

$2.27

Service Code	HCPCS J1455
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.25
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cash Price	$1.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.12
Rate for Payer: Multiplan Commercial	$1.30
Rate for Payer: Multiplan Commercial	$1.53
Rate for Payer: Multiplan Commercial	$1.70

FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]

Facility

$2.30

Service Code	HCPCS J1455
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]

Facility

$2.30

Service Code	HCPCS J1455
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.73

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]

Facility

$96.38

Service Code	NDC 70700-268-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$53.01
Max. Negotiated Rate	$77.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.83
Rate for Payer: Aetna of CA Government/Medicare	$57.83
Rate for Payer: Cash Price	$53.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$77.10
Rate for Payer: Health Smart Auto/Commercial	$57.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.83
Rate for Payer: LLUH Dept of Risk Management WC	$53.01
Rate for Payer: Multiplan Commercial	$72.28

Know your out-of-pocket cost for care.

All Charges