Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

FLURAZEPAM 15 MG CAPSULE [3223]

Facility

$0.60

Service Code	NDC 0378-4415-01
Hospital Charge Code	1730039
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

FLURAZEPAM 15 MG CAPSULE [3223]

Facility

$0.60

Service Code	NDC 0378-4415-01
Hospital Charge Code	1730039
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

FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]

Facility

$7.88

Service Code	NDC 0173-0696-00
Hospital Charge Code	1744100
Hospital Revenue Code	259
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$5.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.73
Rate for Payer: Aetna of CA Government/Medicare	$4.73
Rate for Payer: Cash Price	$3.55
Rate for Payer: Health Smart Auto/Commercial	$4.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.73
Rate for Payer: LLUH Dept of Risk Management WC	$4.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.91

FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [26538]

Facility

$7.88

Service Code	NDC 0173-0696-00
Hospital Charge Code	1744100
Hospital Revenue Code	259
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$6.30
Rate for Payer: Cash Price	$3.55
Rate for Payer: Cigna of CA HMO/PPO	$6.30
Rate for Payer: Health Smart Auto/Commercial	$4.73
Rate for Payer: LLUH Dept of Risk Management WC	$4.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.91

FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]

Facility

$10.36

Service Code	NDC 0173-0697-00
Hospital Charge Code	1744101
Hospital Revenue Code	259
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$7.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.22
Rate for Payer: Aetna of CA Government/Medicare	$6.22
Rate for Payer: Cash Price	$4.66
Rate for Payer: Health Smart Auto/Commercial	$6.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.22
Rate for Payer: LLUH Dept of Risk Management WC	$5.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.77

FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION [104566]

Facility

$10.36

Service Code	NDC 0173-0697-00
Hospital Charge Code	1744101
Hospital Revenue Code	259
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$8.29
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cigna of CA HMO/PPO	$8.29
Rate for Payer: Health Smart Auto/Commercial	$6.22
Rate for Payer: LLUH Dept of Risk Management WC	$5.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.77

FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]

Facility

$27.38

Service Code	NDC 0173-0719-20
Hospital Charge Code	NDG40698
Hospital Revenue Code	259
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$20.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.43
Rate for Payer: Aetna of CA Government/Medicare	$16.43
Rate for Payer: Cash Price	$12.32
Rate for Payer: Health Smart Auto/Commercial	$16.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.43
Rate for Payer: LLUH Dept of Risk Management WC	$15.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.54

FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [40698]

Facility

$27.38

Service Code	NDC 0173-0719-20
Hospital Charge Code	NDG40698
Hospital Revenue Code	259
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$21.90
Rate for Payer: Cash Price	$12.32
Rate for Payer: Cigna of CA HMO/PPO	$21.90
Rate for Payer: Health Smart Auto/Commercial	$16.43
Rate for Payer: LLUH Dept of Risk Management WC	$15.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.54

FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER [40699]

Facility

$42.53

Service Code	NDC 0173-0720-20
Hospital Charge Code	NDG40699
Hospital Revenue Code	259
Min. Negotiated Rate	$23.39
Max. Negotiated Rate	$34.02
Rate for Payer: Cash Price	$19.14
Rate for Payer: Cigna of CA HMO/PPO	$34.02
Rate for Payer: Health Smart Auto/Commercial	$25.52
Rate for Payer: LLUH Dept of Risk Management WC	$23.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.90

FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER [40699]

Facility

$42.53

Service Code	NDC 0173-0720-20
Hospital Charge Code	NDG40699
Hospital Revenue Code	259
Min. Negotiated Rate	$23.39
Max. Negotiated Rate	$31.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.52
Rate for Payer: Aetna of CA Government/Medicare	$25.52
Rate for Payer: Cash Price	$19.14
Rate for Payer: Health Smart Auto/Commercial	$25.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.52
Rate for Payer: LLUH Dept of Risk Management WC	$23.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.90

FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER [40697]

Facility

$23.16

Service Code	NDC 0173-0718-20
Hospital Charge Code	NDG40697
Hospital Revenue Code	259
Min. Negotiated Rate	$12.74
Max. Negotiated Rate	$18.53
Rate for Payer: Cash Price	$10.42
Rate for Payer: Cigna of CA HMO/PPO	$18.53
Rate for Payer: Health Smart Auto/Commercial	$13.90
Rate for Payer: LLUH Dept of Risk Management WC	$12.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.37

FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER [40697]

Facility

$23.16

Service Code	NDC 0173-0718-20
Hospital Charge Code	NDG40697
Hospital Revenue Code	259
Min. Negotiated Rate	$12.74
Max. Negotiated Rate	$17.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.90
Rate for Payer: Aetna of CA Government/Medicare	$13.90
Rate for Payer: Cash Price	$10.42
Rate for Payer: Health Smart Auto/Commercial	$13.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.90
Rate for Payer: LLUH Dept of Risk Management WC	$12.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.37

FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]

Facility

$0.83

Service Code	NDC 60432-264-15
Hospital Charge Code	1744080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.62
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	$0.37
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	$0.62

FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]

Facility

$0.83

Service Code	NDC 60432-264-15
Hospital Charge Code	1744080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
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	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]

Facility

$1.35

Service Code	NDC 60505-0829-1
Hospital Charge Code	1744080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.08
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cigna of CA HMO/PPO	$1.08
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.01

FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [70536]

Facility

$1.35

Service Code	NDC 60505-0829-1
Hospital Charge Code	1744080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.81
Rate for Payer: Aetna of CA Government/Medicare	$0.81
Rate for Payer: Cash Price	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.01

FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [238760]

Facility

$45.55

Service Code	CPT 90686
Hospital Charge Code	NDG238760
Hospital Revenue Code	636
Min. Negotiated Rate	$25.05
Max. Negotiated Rate	$34.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.33
Rate for Payer: Aetna of CA Government/Medicare	$27.33
Rate for Payer: Cash Price	$20.50
Rate for Payer: Health Smart Auto/Commercial	$27.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.33
Rate for Payer: LLUH Dept of Risk Management WC	$25.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.16

FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [238760]

Facility

$45.55

Service Code	CPT 90686
Hospital Charge Code	NDG238760
Hospital Revenue Code	636
Min. Negotiated Rate	$25.05
Max. Negotiated Rate	$36.44
Rate for Payer: Cash Price	$20.50
Rate for Payer: Cigna of CA HMO/PPO	$36.44
Rate for Payer: Health Smart Auto/Commercial	$27.33
Rate for Payer: LLUH Dept of Risk Management WC	$25.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.16

FLU VACCINE QV2023(18YR UP)RCMB(PF)180 MCG(45 MCGX4)/0.5 ML IM SYRINGE [238762]

Facility

$153.02

Service Code	CPT 90682
Hospital Charge Code	RX238762
Hospital Revenue Code	636
Min. Negotiated Rate	$84.16
Max. Negotiated Rate	$122.42
Rate for Payer: Cash Price	$68.86
Rate for Payer: Cash Price	$68.86
Rate for Payer: Cigna of CA HMO/PPO	$122.42
Rate for Payer: Cigna of CA HMO/PPO	$122.42
Rate for Payer: Health Smart Auto/Commercial	$91.82
Rate for Payer: Health Smart Auto/Commercial	$91.81
Rate for Payer: LLUH Dept of Risk Management WC	$84.17
Rate for Payer: LLUH Dept of Risk Management WC	$84.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.77

FLU VACCINE QV2023(18YR UP)RCMB(PF)180 MCG(45 MCGX4)/0.5 ML IM SYRINGE [238762]

Facility

$153.02

Service Code	CPT 90682
Hospital Charge Code	RX238762
Hospital Revenue Code	636
Min. Negotiated Rate	$84.16
Max. Negotiated Rate	$114.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$91.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$91.82
Rate for Payer: Aetna of CA Government/Medicare	$91.81
Rate for Payer: Aetna of CA Government/Medicare	$91.82
Rate for Payer: Cash Price	$68.86
Rate for Payer: Cash Price	$68.86
Rate for Payer: Health Smart Auto/Commercial	$91.81
Rate for Payer: Health Smart Auto/Commercial	$91.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$91.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$91.82
Rate for Payer: LLUH Dept of Risk Management WC	$84.16
Rate for Payer: LLUH Dept of Risk Management WC	$84.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.77

FLUVOXAMINE 100 MG TABLET [10084]

Facility

$0.71

Service Code	NDC 51079-993-01
Hospital Charge Code	1714009
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

FLUVOXAMINE 100 MG TABLET [10084]

Facility

$0.71

Service Code	NDC 51079-993-01
Hospital Charge Code	1714009
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

FLUVOXAMINE 50 MG TABLET [10085]

Facility

$0.60

Service Code	NDC 51079-992-01
Hospital Charge Code	1714008
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

FLUVOXAMINE 50 MG TABLET [10085]

Facility

$0.60

Service Code	NDC 51079-992-20
Hospital Charge Code	1714008
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

FLUVOXAMINE 50 MG TABLET [10085]

Facility

$0.72

Service Code	NDC 62559-159-01
Hospital Charge Code	1714008
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

Know your out-of-pocket cost for care.

All Charges