Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DASATINIB 20 MG TABLET [76717]

Facility

$202.48

Service Code	NDC 0003-0527-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$111.36
Max. Negotiated Rate	$161.98
Rate for Payer: Cash Price	$111.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$161.98
Rate for Payer: Health Smart Auto/Commercial	$121.49
Rate for Payer: LLUH Dept of Risk Management WC	$111.36
Rate for Payer: Multiplan Commercial	$151.86

DASATINIB 20 MG TABLET [76717]

Facility

$202.48

Service Code	NDC 0003-0527-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$111.36
Max. Negotiated Rate	$161.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$121.49
Rate for Payer: Aetna of CA Government/Medicare	$121.49
Rate for Payer: Cash Price	$111.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$161.98
Rate for Payer: Health Smart Auto/Commercial	$121.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$121.49
Rate for Payer: LLUH Dept of Risk Management WC	$111.36
Rate for Payer: Multiplan Commercial	$151.86

DASATINIB 70 MG TABLET [76719]

Facility

$404.95

Service Code	NDC 0003-0524-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$222.72
Max. Negotiated Rate	$323.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$242.97
Rate for Payer: Aetna of CA Government/Medicare	$242.97
Rate for Payer: Cash Price	$222.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$323.96
Rate for Payer: Health Smart Auto/Commercial	$242.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$242.97
Rate for Payer: LLUH Dept of Risk Management WC	$222.72
Rate for Payer: Multiplan Commercial	$303.71

DASATINIB 70 MG TABLET [76719]

Facility

$404.95

Service Code	NDC 0003-0524-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$222.72
Max. Negotiated Rate	$323.96
Rate for Payer: Cash Price	$222.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$323.96
Rate for Payer: Health Smart Auto/Commercial	$242.97
Rate for Payer: LLUH Dept of Risk Management WC	$222.72
Rate for Payer: Multiplan Commercial	$303.71

DASATINIB 80 MG TABLET [108421]

Facility

$729.85

Service Code	NDC 0003-0855-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$401.42
Max. Negotiated Rate	$583.88
Rate for Payer: Cash Price	$401.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$583.88
Rate for Payer: Health Smart Auto/Commercial	$437.91
Rate for Payer: LLUH Dept of Risk Management WC	$401.42
Rate for Payer: Multiplan Commercial	$547.39

DASATINIB 80 MG TABLET [108421]

Facility

$729.85

Service Code	NDC 0003-0855-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$401.42
Max. Negotiated Rate	$583.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$437.91
Rate for Payer: Aetna of CA Government/Medicare	$437.91
Rate for Payer: Cash Price	$401.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$583.88
Rate for Payer: Health Smart Auto/Commercial	$437.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$437.91
Rate for Payer: LLUH Dept of Risk Management WC	$401.42
Rate for Payer: Multiplan Commercial	$547.39

DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]

Facility

$37.08

Service Code	HCPCS J9150
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$29.66
Rate for Payer: Cash Price	$20.39
Rate for Payer: Cash Price	$21.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.47
Rate for Payer: Health Smart Auto/Commercial	$22.25
Rate for Payer: Health Smart Auto/Commercial	$23.60
Rate for Payer: LLUH Dept of Risk Management WC	$21.64
Rate for Payer: LLUH Dept of Risk Management WC	$20.39
Rate for Payer: Multiplan Commercial	$27.81
Rate for Payer: Multiplan Commercial	$29.50

DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]

Facility

$39.34

Service Code	HCPCS J9150
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$31.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.25
Rate for Payer: Aetna of CA Government/Medicare	$23.60
Rate for Payer: Aetna of CA Government/Medicare	$22.25
Rate for Payer: Cash Price	$20.39
Rate for Payer: Cash Price	$21.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.47
Rate for Payer: Health Smart Auto/Commercial	$23.60
Rate for Payer: Health Smart Auto/Commercial	$22.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.25
Rate for Payer: LLUH Dept of Risk Management WC	$20.39
Rate for Payer: LLUH Dept of Risk Management WC	$21.64
Rate for Payer: Multiplan Commercial	$27.81
Rate for Payer: Multiplan Commercial	$29.50

DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]

Facility

$237.60

Service Code	HCPCS J0894
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$130.68
Max. Negotiated Rate	$190.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$142.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$432.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$432.00
Rate for Payer: Aetna of CA Government/Medicare	$142.56
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$130.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$190.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$576.00
Rate for Payer: Health Smart Auto/Commercial	$432.00
Rate for Payer: Health Smart Auto/Commercial	$142.56
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$432.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$142.56
Rate for Payer: LLUH Dept of Risk Management WC	$130.68
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$396.00
Rate for Payer: Multiplan Commercial	$90.00
Rate for Payer: Multiplan Commercial	$540.00
Rate for Payer: Multiplan Commercial	$178.20

DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]

Facility

$120.00

Service Code	HCPCS J0894
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	$130.68
Rate for Payer: Cash Price	$396.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$576.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$190.08
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$142.56
Rate for Payer: Health Smart Auto/Commercial	$432.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$130.68
Rate for Payer: LLUH Dept of Risk Management WC	$396.00
Rate for Payer: Multiplan Commercial	$90.00
Rate for Payer: Multiplan Commercial	$540.00
Rate for Payer: Multiplan Commercial	$178.20

DEFERASIROX 180 MG TABLET [206427]

Facility

$132.38

Service Code	NDC 0078-0655-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$72.81
Max. Negotiated Rate	$105.90
Rate for Payer: Cash Price	$72.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.90
Rate for Payer: Health Smart Auto/Commercial	$79.43
Rate for Payer: LLUH Dept of Risk Management WC	$72.81
Rate for Payer: Multiplan Commercial	$99.28

DEFERASIROX 180 MG TABLET [206427]

Facility

$132.38

Service Code	NDC 0078-0655-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$72.81
Max. Negotiated Rate	$105.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$79.43
Rate for Payer: Aetna of CA Government/Medicare	$79.43
Rate for Payer: Cash Price	$72.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.90
Rate for Payer: Health Smart Auto/Commercial	$79.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$79.43
Rate for Payer: LLUH Dept of Risk Management WC	$72.81
Rate for Payer: Multiplan Commercial	$99.28

DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]

Facility

$123.47

Service Code	NDC 0078-0469-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$67.91
Max. Negotiated Rate	$98.78
Rate for Payer: Cash Price	$67.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$98.78
Rate for Payer: Health Smart Auto/Commercial	$74.08
Rate for Payer: LLUH Dept of Risk Management WC	$67.91
Rate for Payer: Multiplan Commercial	$92.60

DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]

Facility

$123.47

Service Code	NDC 0078-0469-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$67.91
Max. Negotiated Rate	$98.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$74.08
Rate for Payer: Aetna of CA Government/Medicare	$74.08
Rate for Payer: Cash Price	$67.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$98.78
Rate for Payer: Health Smart Auto/Commercial	$74.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$74.08
Rate for Payer: LLUH Dept of Risk Management WC	$67.91
Rate for Payer: Multiplan Commercial	$92.60

DEFERASIROX 360 MG TABLET [206428]

Facility

$264.76

Service Code	NDC 0078-0656-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$145.62
Max. Negotiated Rate	$211.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$158.86
Rate for Payer: Aetna of CA Government/Medicare	$158.86
Rate for Payer: Cash Price	$145.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.81
Rate for Payer: Health Smart Auto/Commercial	$158.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$158.86
Rate for Payer: LLUH Dept of Risk Management WC	$145.62
Rate for Payer: Multiplan Commercial	$198.57

DEFERASIROX 360 MG TABLET [206428]

Facility

$264.76

Service Code	NDC 0078-0656-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$145.62
Max. Negotiated Rate	$211.81
Rate for Payer: Cash Price	$145.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.81
Rate for Payer: Health Smart Auto/Commercial	$158.86
Rate for Payer: LLUH Dept of Risk Management WC	$145.62
Rate for Payer: Multiplan Commercial	$198.57

DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]

Facility

$246.93

Service Code	NDC 0078-0470-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$135.81
Max. Negotiated Rate	$197.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$148.16
Rate for Payer: Aetna of CA Government/Medicare	$148.16
Rate for Payer: Cash Price	$135.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$197.54
Rate for Payer: Health Smart Auto/Commercial	$148.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$148.16
Rate for Payer: LLUH Dept of Risk Management WC	$135.81
Rate for Payer: Multiplan Commercial	$185.20

DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]

Facility

$246.93

Service Code	NDC 0078-0470-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$135.81
Max. Negotiated Rate	$197.54
Rate for Payer: Cash Price	$135.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$197.54
Rate for Payer: Health Smart Auto/Commercial	$148.16
Rate for Payer: LLUH Dept of Risk Management WC	$135.81
Rate for Payer: Multiplan Commercial	$185.20

DEFERASIROX 90 MG TABLET [206426]

Facility

$66.19

Service Code	NDC 0078-0654-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.71
Rate for Payer: Aetna of CA Government/Medicare	$39.71
Rate for Payer: Cash Price	$36.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.95
Rate for Payer: Health Smart Auto/Commercial	$39.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.71
Rate for Payer: LLUH Dept of Risk Management WC	$36.40
Rate for Payer: Multiplan Commercial	$49.64

DEFERASIROX 90 MG TABLET [206426]

Facility

$66.19

Service Code	NDC 0078-0654-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.95
Rate for Payer: Cash Price	$36.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.95
Rate for Payer: Health Smart Auto/Commercial	$39.71
Rate for Payer: LLUH Dept of Risk Management WC	$36.40
Rate for Payer: Multiplan Commercial	$49.64

DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]

Facility

$49.44

Service Code	HCPCS J0895
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$27.19
Max. Negotiated Rate	$39.55
Rate for Payer: Cash Price	$27.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.55
Rate for Payer: Health Smart Auto/Commercial	$29.66
Rate for Payer: LLUH Dept of Risk Management WC	$27.19
Rate for Payer: Multiplan Commercial	$37.08

DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]

Facility

$49.44

Service Code	HCPCS J0895
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$27.19
Max. Negotiated Rate	$39.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.66
Rate for Payer: Aetna of CA Government/Medicare	$29.66
Rate for Payer: Cash Price	$27.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.55
Rate for Payer: Health Smart Auto/Commercial	$29.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.66
Rate for Payer: LLUH Dept of Risk Management WC	$27.19
Rate for Payer: Multiplan Commercial	$37.08

DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]

Facility

$17.71

Service Code	HCPCS J0895
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.74
Max. Negotiated Rate	$14.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.63
Rate for Payer: Aetna of CA Government/Medicare	$10.63
Rate for Payer: Cash Price	$9.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.17
Rate for Payer: Health Smart Auto/Commercial	$10.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.63
Rate for Payer: LLUH Dept of Risk Management WC	$9.74
Rate for Payer: Multiplan Commercial	$13.28

DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]

Facility

$17.71

Service Code	HCPCS J0895
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.74
Max. Negotiated Rate	$14.17
Rate for Payer: Cash Price	$9.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.17
Rate for Payer: Health Smart Auto/Commercial	$10.63
Rate for Payer: LLUH Dept of Risk Management WC	$9.74
Rate for Payer: Multiplan Commercial	$13.28

DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]

Facility

$15.54

Service Code	HCPCS J0895
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$12.43
Rate for Payer: Cash Price	$8.55
Rate for Payer: Cash Price	$9.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.17
Rate for Payer: Health Smart Auto/Commercial	$9.32
Rate for Payer: Health Smart Auto/Commercial	$10.63
Rate for Payer: LLUH Dept of Risk Management WC	$9.74
Rate for Payer: LLUH Dept of Risk Management WC	$8.55
Rate for Payer: Multiplan Commercial	$11.65
Rate for Payer: Multiplan Commercial	$13.28

Know your out-of-pocket cost for care.

All Charges