Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]

Facility

$0.69

Service Code	NDC 54838-523-40
Hospital Charge Code	1715117
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

FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]

Facility

$0.69

Service Code	NDC 54838-523-40
Hospital Charge Code	1715117
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

FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]

Facility

$1.37

Service Code	NDC 0121-4721-05
Hospital Charge Code	1716061
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.03

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.08

Service Code	NDC 68001-400-00
Hospital Charge Code	1711185
Hospital Revenue Code	259
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	$0.04
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 Beech St/Commercial/PHCS	$0.06

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.16

Service Code	NDC 68084-605-01
Hospital Charge Code	1711185
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

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.07

Service Code	NDC 50111-648-01
Hospital Charge Code	1711185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.11

Service Code	NDC 0904-5785-61
Hospital Charge Code	1711185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.16

Service Code	NDC 68084-605-11
Hospital Charge Code	1711185
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

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.08

Service Code	NDC 65862-193-01
Hospital Charge Code	1711185
Hospital Revenue Code	259
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	$0.04
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 Beech St/Commercial/PHCS	$0.06

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.16

Service Code	NDC 68084-605-01
Hospital Charge Code	1711185
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

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.08

Service Code	NDC 68001-400-00
Hospital Charge Code	1711185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.06

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.11

Service Code	NDC 0904-5785-61
Hospital Charge Code	1711185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.07

Service Code	NDC 50111-648-01
Hospital Charge Code	1711185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.16

Service Code	NDC 68084-605-11
Hospital Charge Code	1711185
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

FLUOXETINE 20 MG CAPSULE [10070]

Facility

$0.08

Service Code	NDC 65862-193-01
Hospital Charge Code	1711185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.06

FLUOXETINE 20 MG TABLET [17463]

Facility

$0.38

Service Code	NDC 59651-309-30
Hospital Charge Code	ERX17463
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

FLUOXETINE 20 MG TABLET [17463]

Facility

$0.38

Service Code	NDC 59651-309-30
Hospital Charge Code	ERX17463
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

FLUPHENAZINE 2.5 MG/5 ML ORAL ELIXIR [10072]

Facility

$0.64

Service Code	NDC 0121-0654-02
Hospital Charge Code	NDG10072
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

FLUPHENAZINE 2.5 MG/5 ML ORAL ELIXIR [10072]

Facility

$0.64

Service Code	NDC 0121-0654-02
Hospital Charge Code	NDG10072
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

FLUPHENAZINE 2.5 MG TABLET [3220]

Facility

$2.78

Service Code	NDC 0527-1789-01
Hospital Charge Code	1710622
Hospital Revenue Code	259
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.67
Rate for Payer: Aetna of CA Government/Medicare	$1.67
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Smart Auto/Commercial	$1.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.67
Rate for Payer: LLUH Dept of Risk Management WC	$1.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.08

FLUPHENAZINE 2.5 MG TABLET [3220]

Facility

$1.29

Service Code	NDC 69238-1679-1
Hospital Charge Code	1710622
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$0.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.97

FLUPHENAZINE 2.5 MG TABLET [3220]

Facility

$2.78

Service Code	NDC 0527-1789-01
Hospital Charge Code	1710622
Hospital Revenue Code	259
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.22
Rate for Payer: Cash Price	$1.25
Rate for Payer: Cigna of CA HMO/PPO	$2.22
Rate for Payer: Health Smart Auto/Commercial	$1.67
Rate for Payer: LLUH Dept of Risk Management WC	$1.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.08

FLUPHENAZINE 2.5 MG TABLET [3220]

Facility

$1.29

Service Code	NDC 69238-1679-1
Hospital Charge Code	1710622
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.03
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.97

FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]

Facility

$29.04

Service Code	CPT J2680
Hospital Charge Code	1720193
Hospital Revenue Code	636
Min. Negotiated Rate	$15.97
Max. Negotiated Rate	$21.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.42
Rate for Payer: Aetna of CA Government/Medicare	$17.42
Rate for Payer: Cash Price	$13.07
Rate for Payer: Health Smart Auto/Commercial	$17.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.42
Rate for Payer: LLUH Dept of Risk Management WC	$15.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.78

FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION [3215]

Facility

$29.04

Service Code	CPT J2680
Hospital Charge Code	1720193
Hospital Revenue Code	636
Min. Negotiated Rate	$15.97
Max. Negotiated Rate	$23.23
Rate for Payer: Cash Price	$13.07
Rate for Payer: Cigna of CA HMO/PPO	$23.23
Rate for Payer: Health Smart Auto/Commercial	$17.42
Rate for Payer: LLUH Dept of Risk Management WC	$15.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.78

Know your out-of-pocket cost for care.

All Charges