Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

VORICONAZOLE 200 MG TABLET [33009]

Facility

$9.00

Service Code	NDC 68462-573-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

VORICONAZOLE 200 MG TABLET [33009]

Facility

$21.43

Service Code	NDC 50268-803-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.79
Max. Negotiated Rate	$17.14
Rate for Payer: Cash Price	$11.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.14
Rate for Payer: Health Smart Auto/Commercial	$12.86
Rate for Payer: LLUH Dept of Risk Management WC	$11.79
Rate for Payer: Multiplan Commercial	$16.07

VORICONAZOLE 200 MG TABLET [33009]

Facility

$9.00

Service Code	NDC 68462-573-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

VORICONAZOLE 50 MG TABLET [33008]

Facility

$2.60

Service Code	NDC 27241-062-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

VORICONAZOLE 50 MG TABLET [33008]

Facility

$2.60

Service Code	NDC 27241-062-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.56
Rate for Payer: Aetna of CA Government/Medicare	$1.56
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

VORICONAZOLE 50 MG TABLET [33008]

Facility

$2.60

Service Code	NDC 68462-572-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

VORICONAZOLE 50 MG TABLET [33008]

Facility

$2.60

Service Code	NDC 68462-572-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.56
Rate for Payer: Aetna of CA Government/Medicare	$1.56
Rate for Payer: Cash Price	$1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Commercial	$1.95

VORINOSTAT 100 MG CAPSULE [77539]

Facility

$150.10

Service Code	NDC 0006-0568-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$82.56
Max. Negotiated Rate	$120.08
Rate for Payer: Cash Price	$82.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.08
Rate for Payer: Health Smart Auto/Commercial	$90.06
Rate for Payer: LLUH Dept of Risk Management WC	$82.56
Rate for Payer: Multiplan Commercial	$112.58

VORINOSTAT 100 MG CAPSULE [77539]

Facility

$150.10

Service Code	NDC 0006-0568-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$82.56
Max. Negotiated Rate	$120.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.06
Rate for Payer: Aetna of CA Government/Medicare	$90.06
Rate for Payer: Cash Price	$82.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.08
Rate for Payer: Health Smart Auto/Commercial	$90.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.06
Rate for Payer: LLUH Dept of Risk Management WC	$82.56
Rate for Payer: Multiplan Commercial	$112.58

VORINOSTAT ORAL SUSPENSION COMPOUND 50 MG/ML [4080357]

Facility

$49.35

Service Code	NDC 9994-0803-57
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$39.48
Rate for Payer: Cash Price	$27.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.48
Rate for Payer: Health Smart Auto/Commercial	$29.61
Rate for Payer: LLUH Dept of Risk Management WC	$27.14
Rate for Payer: Multiplan Commercial	$37.01

VORINOSTAT ORAL SUSPENSION COMPOUND 50 MG/ML [4080357]

Facility

$49.35

Service Code	NDC 9994-0803-57
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$39.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.61
Rate for Payer: Aetna of CA Government/Medicare	$29.61
Rate for Payer: Cash Price	$27.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.48
Rate for Payer: Health Smart Auto/Commercial	$29.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.61
Rate for Payer: LLUH Dept of Risk Management WC	$27.14
Rate for Payer: Multiplan Commercial	$37.01

WARFARIN 0.5 MG PARTIAL TABLET [4081492]

Facility

$0.26

Service Code	NDC 9994-0814-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

WARFARIN 0.5 MG PARTIAL TABLET [4081492]

Facility

$0.26

Service Code	NDC 9994-0814-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

WARFARIN 10 MG TABLET [8748]

Facility

$0.44

Service Code	NDC 0093-1720-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-89
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

WARFARIN 10 MG TABLET [8748]

Facility

$0.44

Service Code	NDC 0093-1720-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-89
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

WARFARIN 10 MG TABLET [8748]

Facility

$0.73

Service Code	NDC 0832-1219-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

WARFARIN 1.25 MG PARTIAL TABLET [4081918]

Facility

$1.33

Service Code	NDC 9994-0819-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$1.00

WARFARIN 1.25 MG PARTIAL TABLET [4081918]

Facility

$1.33

Service Code	NDC 9994-0819-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$1.00

WARFARIN 1 MG TABLET [11664]

Facility

$0.26

Service Code	NDC 0093-1712-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

WARFARIN 1 MG TABLET [11664]

Facility

$0.26

Service Code	NDC 0093-1712-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

WARFARIN 1 MG TABLET [11664]

Facility

$0.19

Service Code	NDC 57237-119-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

WARFARIN 1 MG TABLET [11664]

Facility

$0.44

Service Code	NDC 0832-1211-89
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

Know your out-of-pocket cost for care.

All Charges