Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]

Facility

$573.60

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$315.48
Max. Negotiated Rate	$458.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$344.16
Rate for Payer: Aetna of CA Government/Medicare	$344.16
Rate for Payer: Cash Price	$315.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$458.88
Rate for Payer: Health Smart Auto/Commercial	$344.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$344.16
Rate for Payer: LLUH Dept of Risk Management WC	$315.48
Rate for Payer: Multiplan Commercial	$430.20

DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]

Facility

$573.60

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$315.48
Max. Negotiated Rate	$458.88
Rate for Payer: Cash Price	$315.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$458.88
Rate for Payer: Health Smart Auto/Commercial	$344.16
Rate for Payer: LLUH Dept of Risk Management WC	$315.48
Rate for Payer: Multiplan Commercial	$430.20

DEGARELIX 80 MG SUBCUTANEOUS SOLUTION [96986]

Facility

$586.14

Service Code	HCPCS J9155
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$322.38
Max. Negotiated Rate	$468.91
Rate for Payer: Cash Price	$322.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$468.91
Rate for Payer: Health Smart Auto/Commercial	$351.68
Rate for Payer: LLUH Dept of Risk Management WC	$322.38
Rate for Payer: Multiplan Commercial	$439.61

DEGARELIX 80 MG SUBCUTANEOUS SOLUTION [96986]

Facility

$586.14

Service Code	HCPCS J9155
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$322.38
Max. Negotiated Rate	$468.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$351.68
Rate for Payer: Aetna of CA Government/Medicare	$351.68
Rate for Payer: Cash Price	$322.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$468.91
Rate for Payer: Health Smart Auto/Commercial	$351.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$351.68
Rate for Payer: LLUH Dept of Risk Management WC	$322.38
Rate for Payer: Multiplan Commercial	$439.61

DESIPRAMINE 25 MG TABLET [2286]

Facility

$1.34

Service Code	NDC 45963-342-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
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	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
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	$0.74
Rate for Payer: Multiplan Commercial	$1.00

DESIPRAMINE 25 MG TABLET [2286]

Facility

$0.18

Service Code	NDC 50742-113-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

DESIPRAMINE 25 MG TABLET [2286]

Facility

$1.34

Service Code	NDC 45963-342-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

DESIPRAMINE 25 MG TABLET [2286]

Facility

$0.18

Service Code	NDC 50742-113-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$0.88

Service Code	NDC 68001-574-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$2.63

Service Code	NDC 60687-721-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Commercial	$1.97

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$0.88

Service Code	NDC 60505-0257-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$0.88

Service Code	NDC 68001-574-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$0.88

Service Code	NDC 60505-0257-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.66

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$2.63

Service Code	NDC 60687-721-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.58
Rate for Payer: Aetna of CA Government/Medicare	$1.58
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Commercial	$1.97

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$2.63

Service Code	NDC 60687-721-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.58
Rate for Payer: Aetna of CA Government/Medicare	$1.58
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Commercial	$1.97

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$2.63

Service Code	NDC 60687-721-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Commercial	$1.97

DESMOPRESSIN 0.2 MG TABLET [16053]

Facility

$0.99

Service Code	NDC 68001-575-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

DESMOPRESSIN 0.2 MG TABLET [16053]

Facility

$0.99

Service Code	NDC 60505-0258-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

DESMOPRESSIN 0.2 MG TABLET [16053]

Facility

$0.99

Service Code	NDC 60505-0258-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

DESMOPRESSIN 0.2 MG TABLET [16053]

Facility

$0.99

Service Code	NDC 68001-575-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]

Facility

$47.28

Service Code	NDC 24208-342-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$37.82
Rate for Payer: Cash Price	$26.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.82
Rate for Payer: Health Smart Auto/Commercial	$28.37
Rate for Payer: LLUH Dept of Risk Management WC	$26.00
Rate for Payer: Multiplan Commercial	$35.46

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]

Facility

$47.28

Service Code	NDC 24208-342-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$37.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.37
Rate for Payer: Aetna of CA Government/Medicare	$28.37
Rate for Payer: Cash Price	$26.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.82
Rate for Payer: Health Smart Auto/Commercial	$28.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.37
Rate for Payer: LLUH Dept of Risk Management WC	$26.00
Rate for Payer: Multiplan Commercial	$35.46

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED) [21135]

Facility

$29.55

Service Code	NDC 47335-788-91
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$23.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.73
Rate for Payer: Aetna of CA Government/Medicare	$17.73
Rate for Payer: Cash Price	$16.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.64
Rate for Payer: Health Smart Auto/Commercial	$17.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.73
Rate for Payer: LLUH Dept of Risk Management WC	$16.25
Rate for Payer: Multiplan Commercial	$22.16

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED) [21135]

Facility

$29.55

Service Code	NDC 47335-788-91
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$23.64
Rate for Payer: Cash Price	$16.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.64
Rate for Payer: Health Smart Auto/Commercial	$17.73
Rate for Payer: LLUH Dept of Risk Management WC	$16.25
Rate for Payer: Multiplan Commercial	$22.16

Know your out-of-pocket cost for care.

All Charges