Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DESMOPRESSIN 25 MCG 1/4 TAB [4080522]

Facility

$3.02

Service Code	NDC 9994-0805-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.81
Rate for Payer: Aetna of CA Government/Medicare	$1.81
Rate for Payer: Cash Price	$1.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.66
Rate for Payer: Multiplan Commercial	$2.27

DESMOPRESSIN 25 MCG 1/4 TAB [4080522]

Facility

$3.02

Service Code	NDC 9994-0805-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$2.42
Rate for Payer: Cash Price	$1.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.66
Rate for Payer: Multiplan Commercial	$2.27

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$19.20

Service Code	HCPCS J2597
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$15.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.80
Rate for Payer: Aetna of CA Government/Medicare	$28.44
Rate for Payer: Aetna of CA Government/Medicare	$11.52
Rate for Payer: Aetna of CA Government/Medicare	$23.14
Rate for Payer: Aetna of CA Government/Medicare	$37.80
Rate for Payer: Cash Price	$26.07
Rate for Payer: Cash Price	$34.65
Rate for Payer: Cash Price	$10.56
Rate for Payer: Cash Price	$21.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$50.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.36
Rate for Payer: Health Smart Auto/Commercial	$11.52
Rate for Payer: Health Smart Auto/Commercial	$28.44
Rate for Payer: Health Smart Auto/Commercial	$23.14
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.07
Rate for Payer: LLUH Dept of Risk Management WC	$21.21
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: LLUH Dept of Risk Management WC	$10.56
Rate for Payer: Multiplan Commercial	$35.55
Rate for Payer: Multiplan Commercial	$47.25
Rate for Payer: Multiplan Commercial	$28.93
Rate for Payer: Multiplan Commercial	$14.40

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$63.00

Service Code	HCPCS J2597
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$50.40
Rate for Payer: Cash Price	$34.65
Rate for Payer: Cash Price	$26.07
Rate for Payer: Cash Price	$10.56
Rate for Payer: Cash Price	$21.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$50.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.36
Rate for Payer: Health Smart Auto/Commercial	$11.52
Rate for Payer: Health Smart Auto/Commercial	$28.44
Rate for Payer: Health Smart Auto/Commercial	$23.14
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: LLUH Dept of Risk Management WC	$21.21
Rate for Payer: LLUH Dept of Risk Management WC	$10.56
Rate for Payer: LLUH Dept of Risk Management WC	$26.07
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: Multiplan Commercial	$28.93
Rate for Payer: Multiplan Commercial	$47.25
Rate for Payer: Multiplan Commercial	$14.40
Rate for Payer: Multiplan Commercial	$35.55

DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]

Facility

$0.30

Service Code	NDC 9994-0804-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]

Facility

$0.30

Service Code	NDC 9994-0804-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$1.85

Service Code	NDC 51672-1281-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.11
Rate for Payer: Aetna of CA Government/Medicare	$1.11
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$1.85

Service Code	NDC 51672-1281-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$1.85

Service Code	NDC 51672-1281-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$1.85

Service Code	NDC 51672-1281-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.11
Rate for Payer: Aetna of CA Government/Medicare	$1.11
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$3.29

Service Code	NDC 45802-495-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.63
Rate for Payer: Cash Price	$1.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.63
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Commercial	$2.47

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$3.29

Service Code	NDC 45802-495-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.97
Rate for Payer: Aetna of CA Government/Medicare	$1.97
Rate for Payer: Cash Price	$1.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.63
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Commercial	$2.47

DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]

Facility

$1.17

Service Code	NDC 51991-006-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.88

DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR [205849]

Facility

$1.17

Service Code	NDC 51991-006-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.88

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.51
Rate for Payer: Aetna of CA Government/Medicare	$10.51
Rate for Payer: Cash Price	$9.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Commercial	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$0.80

Service Code	NDC 59762-1211-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$0.80

Service Code	NDC 59762-1211-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$1.27

Service Code	NDC 0054-0400-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.95

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.51
Rate for Payer: Aetna of CA Government/Medicare	$10.51
Rate for Payer: Cash Price	$9.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Commercial	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Cash Price	$9.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Commercial	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$1.27

Service Code	NDC 0054-0400-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
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	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
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	$0.70
Rate for Payer: Multiplan Commercial	$0.95

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$1.27

Service Code	NDC 0054-0400-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
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	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
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	$0.70
Rate for Payer: Multiplan Commercial	$0.95

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Cash Price	$9.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Commercial	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$1.27

Service Code	NDC 0054-0400-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.95

DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]

Facility

$38.40

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$21.12
Max. Negotiated Rate	$30.72
Rate for Payer: Cash Price	$21.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.72
Rate for Payer: Health Smart Auto/Commercial	$23.04
Rate for Payer: LLUH Dept of Risk Management WC	$21.12
Rate for Payer: Multiplan Commercial	$28.80

Know your out-of-pocket cost for care.

All Charges