Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.37

Service Code	NDC 60687-744-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.62
Rate for Payer: Aetna of CA Government/Medicare	$8.62
Rate for Payer: Cash Price	$7.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.50
Rate for Payer: Health Smart Auto/Commercial	$8.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.62
Rate for Payer: LLUH Dept of Risk Management WC	$7.90
Rate for Payer: Multiplan Commercial	$10.78

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$14.87

Service Code	HCPCS J9130
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.18
Max. Negotiated Rate	$11.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.92
Rate for Payer: Aetna of CA Government/Medicare	$8.92
Rate for Payer: Cash Price	$8.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.90
Rate for Payer: Health Smart Auto/Commercial	$8.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.92
Rate for Payer: LLUH Dept of Risk Management WC	$8.18
Rate for Payer: Multiplan Commercial	$11.15

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$14.87

Service Code	HCPCS J9130
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.18
Max. Negotiated Rate	$11.90
Rate for Payer: Cash Price	$8.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.90
Rate for Payer: Health Smart Auto/Commercial	$8.92
Rate for Payer: LLUH Dept of Risk Management WC	$8.18
Rate for Payer: Multiplan Commercial	$11.15

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$14.40

Service Code	HCPCS J9130
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$11.52
Rate for Payer: Cash Price	$7.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.52
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Commercial	$10.80

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$14.40

Service Code	HCPCS J9130
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$11.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.64
Rate for Payer: Aetna of CA Government/Medicare	$8.64
Rate for Payer: Cash Price	$7.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.52
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.64
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Commercial	$10.80

DACOMITINIB 15 MG TABLET [222938]

Facility

$660.40

Service Code	NDC 0069-0197-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$363.22
Max. Negotiated Rate	$528.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$396.24
Rate for Payer: Aetna of CA Government/Medicare	$396.24
Rate for Payer: Cash Price	$363.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.32
Rate for Payer: Health Smart Auto/Commercial	$396.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$396.24
Rate for Payer: LLUH Dept of Risk Management WC	$363.22
Rate for Payer: Multiplan Commercial	$495.30

DACOMITINIB 15 MG TABLET [222938]

Facility

$660.40

Service Code	NDC 0069-0197-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$363.22
Max. Negotiated Rate	$528.32
Rate for Payer: Cash Price	$363.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.32
Rate for Payer: Health Smart Auto/Commercial	$396.24
Rate for Payer: LLUH Dept of Risk Management WC	$363.22
Rate for Payer: Multiplan Commercial	$495.30

DACOMITINIB 30 MG TABLET [222939]

Facility

$660.40

Service Code	NDC 0069-1198-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$363.22
Max. Negotiated Rate	$528.32
Rate for Payer: Cash Price	$363.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.32
Rate for Payer: Health Smart Auto/Commercial	$396.24
Rate for Payer: LLUH Dept of Risk Management WC	$363.22
Rate for Payer: Multiplan Commercial	$495.30

DACOMITINIB 30 MG TABLET [222939]

Facility

$660.40

Service Code	NDC 0069-1198-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$363.22
Max. Negotiated Rate	$528.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$396.24
Rate for Payer: Aetna of CA Government/Medicare	$396.24
Rate for Payer: Cash Price	$363.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.32
Rate for Payer: Health Smart Auto/Commercial	$396.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$396.24
Rate for Payer: LLUH Dept of Risk Management WC	$363.22
Rate for Payer: Multiplan Commercial	$495.30

DACOMITINIB 45 MG TABLET [222940]

Facility

$660.40

Service Code	NDC 0069-2299-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$363.22
Max. Negotiated Rate	$528.32
Rate for Payer: Cash Price	$363.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.32
Rate for Payer: Health Smart Auto/Commercial	$396.24
Rate for Payer: LLUH Dept of Risk Management WC	$363.22
Rate for Payer: Multiplan Commercial	$495.30

DACOMITINIB 45 MG TABLET [222940]

Facility

$660.40

Service Code	NDC 0069-2299-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$363.22
Max. Negotiated Rate	$528.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$396.24
Rate for Payer: Aetna of CA Government/Medicare	$396.24
Rate for Payer: Cash Price	$363.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.32
Rate for Payer: Health Smart Auto/Commercial	$396.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$396.24
Rate for Payer: LLUH Dept of Risk Management WC	$363.22
Rate for Payer: Multiplan Commercial	$495.30

DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]

Facility

$885.00

Service Code	HCPCS J9120
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$486.75
Max. Negotiated Rate	$708.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$531.00
Rate for Payer: Aetna of CA Government/Medicare	$531.00
Rate for Payer: Cash Price	$486.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$708.00
Rate for Payer: Health Smart Auto/Commercial	$531.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$531.00
Rate for Payer: LLUH Dept of Risk Management WC	$486.75
Rate for Payer: Multiplan Commercial	$663.75

DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]

Facility

$885.00

Service Code	HCPCS J9120
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$486.75
Max. Negotiated Rate	$708.00
Rate for Payer: Cash Price	$486.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$708.00
Rate for Payer: Health Smart Auto/Commercial	$531.00
Rate for Payer: LLUH Dept of Risk Management WC	$486.75
Rate for Payer: Multiplan Commercial	$663.75

DANAZOL 200 MG CAPSULE [2120]

Facility

$8.64

Service Code	NDC 0527-1369-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$6.91
Rate for Payer: Cash Price	$4.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.91
Rate for Payer: Health Smart Auto/Commercial	$5.18
Rate for Payer: LLUH Dept of Risk Management WC	$4.75
Rate for Payer: Multiplan Commercial	$6.48

DANAZOL 200 MG CAPSULE [2120]

Facility

$7.61

Service Code	NDC 0527-1369-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$6.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.57
Rate for Payer: Aetna of CA Government/Medicare	$4.57
Rate for Payer: Cash Price	$4.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.09
Rate for Payer: Health Smart Auto/Commercial	$4.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.57
Rate for Payer: LLUH Dept of Risk Management WC	$4.19
Rate for Payer: Multiplan Commercial	$5.71

DANAZOL 200 MG CAPSULE [2120]

Facility

$7.61

Service Code	NDC 0527-1369-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$6.09
Rate for Payer: Cash Price	$4.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.09
Rate for Payer: Health Smart Auto/Commercial	$4.57
Rate for Payer: LLUH Dept of Risk Management WC	$4.19
Rate for Payer: Multiplan Commercial	$5.71

DANAZOL 200 MG CAPSULE [2120]

Facility

$8.64

Service Code	NDC 0527-1369-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$6.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.18
Rate for Payer: Aetna of CA Government/Medicare	$5.18
Rate for Payer: Cash Price	$4.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.91
Rate for Payer: Health Smart Auto/Commercial	$5.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.18
Rate for Payer: LLUH Dept of Risk Management WC	$4.75
Rate for Payer: Multiplan Commercial	$6.48

DANTROLENE 100 MG CAPSULE [9717]

Facility

$1.57

Service Code	NDC 49884-364-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.18

DANTROLENE 100 MG CAPSULE [9717]

Facility

$1.97

Service Code	NDC 0115-4433-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.18
Rate for Payer: Aetna of CA Government/Medicare	$1.18
Rate for Payer: Cash Price	$1.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: Multiplan Commercial	$1.48

DANTROLENE 100 MG CAPSULE [9717]

Facility

$1.57

Service Code	NDC 49884-364-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.18

DANTROLENE 100 MG CAPSULE [9717]

Facility

$1.97

Service Code	NDC 0115-4433-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.58
Rate for Payer: Cash Price	$1.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: Multiplan Commercial	$1.48

DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]

Facility

$84.00

Service Code	NDC 78670-003-67
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Cash Price	$46.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00

DANTROLENE 20 MG INTRAVENOUS SOLUTION [9716]

Facility

$84.00

Service Code	NDC 78670-003-67
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Cash Price	$46.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00

DANTROLENE 25 MG CAPSULE [9718]

Facility

$0.97

Service Code	NDC 0115-4411-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.73

DANTROLENE 25 MG CAPSULE [9718]

Facility

$1.95

Service Code	NDC 68084-300-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.56
Rate for Payer: Cash Price	$1.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.56
Rate for Payer: Health Smart Auto/Commercial	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.07
Rate for Payer: Multiplan Commercial	$1.46

Know your out-of-pocket cost for care.

All Charges