Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.69

Service Code	NDC 0054-0010-25
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
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	$0.31
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 Beech St/Commercial/PHCS	$0.52

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.69

Service Code	NDC 0054-0010-25
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.52

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.52

Service Code	NDC 65862-621-01
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.69

Service Code	NDC 0054-0010-21
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.52

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.52

Service Code	NDC 65862-621-01
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.39
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	$0.23
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	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.16

Service Code	NDC 62559-380-01
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.69

Service Code	NDC 0054-0010-21
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
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	$0.31
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 Beech St/Commercial/PHCS	$0.52

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.16

Service Code	NDC 62559-380-01
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

FLECAINIDE 50 MG TABLET [10043]

Facility

$0.69

Service Code	NDC 0054-0010-20
Hospital Charge Code	1711525
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.52

FLECAINIDE ORAL SUSPENSION COMPOUND 20 MG/ML [4080273]

Facility

$0.55

Service Code	NDC 9994-0802-73
Hospital Charge Code	1715085
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

FLECAINIDE ORAL SUSPENSION COMPOUND 20 MG/ML [4080273]

Facility

$0.55

Service Code	NDC 9994-0802-73
Hospital Charge Code	1715085
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

FLORBETABEN F-18 8.1 MCI (300 MBQ) INTRAVENOUS SOLUTION [231724]

Facility

$3,360.00

Service Code	CPT Q9983
Hospital Revenue Code	343
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$2,520.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,016.00
Rate for Payer: Aetna of CA Government/Medicare	$2,016.00
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Health Smart Auto/Commercial	$2,016.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,016.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,848.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,520.00

FLORBETABEN F-18 8.1 MCI (300 MBQ) INTRAVENOUS SOLUTION [231724]

Facility

$3,360.00

Service Code	CPT Q9983
Hospital Revenue Code	343
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$2,688.00
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Cigna of CA HMO/PPO	$2,688.00
Rate for Payer: Health Smart Auto/Commercial	$2,016.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,848.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,520.00

FLORBETAPIR F-18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [196481]

Facility

$342.12

Service Code	CPT A9586
Hospital Charge Code	ERX196481
Hospital Revenue Code	343
Min. Negotiated Rate	$188.17
Max. Negotiated Rate	$273.70
Rate for Payer: Cash Price	$153.95
Rate for Payer: Cigna of CA HMO/PPO	$273.70
Rate for Payer: Health Smart Auto/Commercial	$205.27
Rate for Payer: LLUH Dept of Risk Management WC	$188.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.59

FLORBETAPIR F-18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [196481]

Facility

$342.12

Service Code	CPT A9586
Hospital Charge Code	ERX196481
Hospital Revenue Code	343
Min. Negotiated Rate	$188.17
Max. Negotiated Rate	$256.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$205.27
Rate for Payer: Aetna of CA Government/Medicare	$205.27
Rate for Payer: Cash Price	$153.95
Rate for Payer: Health Smart Auto/Commercial	$205.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$205.27
Rate for Payer: LLUH Dept of Risk Management WC	$188.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.59

FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [219653]

Facility

$5,760.00

Service Code	CPT A9588
Hospital Charge Code	ERX219653
Hospital Revenue Code	343
Min. Negotiated Rate	$3,168.00
Max. Negotiated Rate	$4,608.00
Rate for Payer: Cash Price	$2,592.00
Rate for Payer: Cigna of CA HMO/PPO	$4,608.00
Rate for Payer: Health Smart Auto/Commercial	$3,456.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,168.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,320.00

FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION [219653]

Facility

$5,760.00

Service Code	CPT A9588
Hospital Charge Code	ERX219653
Hospital Revenue Code	343
Min. Negotiated Rate	$3,168.00
Max. Negotiated Rate	$4,320.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,456.00
Rate for Payer: Aetna of CA Government/Medicare	$3,456.00
Rate for Payer: Cash Price	$2,592.00
Rate for Payer: Health Smart Auto/Commercial	$3,456.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,456.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,168.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,320.00

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$1.79

Service Code	NDC 68001-252-04
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.43
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$0.60

Service Code	NDC 57237-004-30
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$1.20

Service Code	NDC 67405-602-03
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$0.60

Service Code	NDC 57237-004-30
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$0.84

Service Code	NDC 70710-1138-3
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$1.20

Service Code	NDC 67405-602-03
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$0.84

Service Code	NDC 70710-1138-3
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.63

FLUCONAZOLE 100 MG TABLET [10044]

Facility

$1.79

Service Code	NDC 68001-252-04
Hospital Charge Code	1711488
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

Know your out-of-pocket cost for care.

All Charges