Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

$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: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.78

Service Code	NDC 49884-362-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

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: Aetna of CA EPO/HMO/POS/PPO	$1.17
Rate for Payer: Aetna of CA Government/Medicare	$1.17
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.07
Rate for Payer: Multiplan Commercial	$1.46

DANTROLENE 50 MG CAPSULE [9719]

Facility

$1.57

Service Code	NDC 0115-4422-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.86
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 50 MG CAPSULE [9719]

Facility

$1.57

Service Code	NDC 0115-4422-01
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	$0.86
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 50 MG CAPSULE [9719]

Facility

$1.26

Service Code	NDC 49884-363-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.01
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.95

DANTROLENE 50 MG CAPSULE [9719]

Facility

$1.26

Service Code	NDC 49884-363-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.95

DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]

Facility

$0.11

Service Code	NDC 9994-0802-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.08

DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]

Facility

$0.11

Service Code	NDC 9994-0802-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
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	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
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 Commercial	$0.08

DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]

Facility

$23.99

Service Code	NDC 0310-6210-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$19.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.39
Rate for Payer: Aetna of CA Government/Medicare	$14.39
Rate for Payer: Cash Price	$13.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.19
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Commercial	$17.99

DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]

Facility

$15.14

Service Code	NDC 66993-457-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$12.11
Rate for Payer: Cash Price	$8.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.11
Rate for Payer: Health Smart Auto/Commercial	$9.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.33
Rate for Payer: Multiplan Commercial	$11.36

DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]

Facility

$15.14

Service Code	NDC 66993-457-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.33
Max. Negotiated Rate	$12.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.08
Rate for Payer: Aetna of CA Government/Medicare	$9.08
Rate for Payer: Cash Price	$8.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.11
Rate for Payer: Health Smart Auto/Commercial	$9.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.33
Rate for Payer: Multiplan Commercial	$11.36

DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]

Facility

$23.99

Service Code	NDC 0310-6210-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$19.19
Rate for Payer: Cash Price	$13.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.19
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Commercial	$17.99

DAPSONE 100 MG TABLET [2131]

Facility

$1.86

Service Code	NDC 64980-566-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.49
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.49
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.40

DAPSONE 100 MG TABLET [2131]

Facility

$1.45

Service Code	NDC 70954-136-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.87
Rate for Payer: Aetna of CA Government/Medicare	$0.87
Rate for Payer: Cash Price	$0.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.16
Rate for Payer: Health Smart Auto/Commercial	$0.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.87
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$1.09

DAPSONE 100 MG TABLET [2131]

Facility

$1.86

Service Code	NDC 64980-566-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.12
Rate for Payer: Aetna of CA Government/Medicare	$1.12
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.49
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.40

DAPSONE 100 MG TABLET [2131]

Facility

$1.45

Service Code	NDC 70954-136-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.16
Rate for Payer: Health Smart Auto/Commercial	$0.87
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$1.09

DAPSONE 25 MG TABLET [2132]

Facility

$2.74

Service Code	NDC 49938-102-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.64
Rate for Payer: Aetna of CA Government/Medicare	$1.64
Rate for Payer: Cash Price	$1.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.19
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Commercial	$2.06

DAPSONE 25 MG TABLET [2132]

Facility

$2.74

Service Code	NDC 49938-102-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.19
Rate for Payer: Cash Price	$1.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.19
Rate for Payer: Health Smart Auto/Commercial	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Commercial	$2.06

DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]

Facility

$2.37

Service Code	NDC 9994-0802-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Commercial	$1.78

DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]

Facility

$2.37

Service Code	NDC 9994-0802-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.42
Rate for Payer: Aetna of CA Government/Medicare	$1.42
Rate for Payer: Cash Price	$1.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.90
Rate for Payer: Health Smart Auto/Commercial	$1.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.30
Rate for Payer: Multiplan Commercial	$1.78

DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]

Facility

$120.00

Service Code	HCPCS J0878
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$96.00
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$90.00
Rate for Payer: Multiplan Commercial	$27.00

DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]

Facility

$36.00

Service Code	HCPCS J0878
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00
Rate for Payer: Multiplan Commercial	$90.00

DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [228045]

Facility

$845.75

Service Code	HCPCS J9144
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$465.16
Max. Negotiated Rate	$676.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$507.45
Rate for Payer: Aetna of CA Government/Medicare	$507.45
Rate for Payer: Cash Price	$465.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$676.60
Rate for Payer: Health Smart Auto/Commercial	$507.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$507.45
Rate for Payer: LLUH Dept of Risk Management WC	$465.16
Rate for Payer: Multiplan Commercial	$634.31

Know your out-of-pocket cost for care.

All Charges