Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]

Facility

$1.22

Service Code	CPT J9100
Hospital Charge Code	NDG20156
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.75
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.75
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cash Price	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.92

CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION [20156]

Facility

$1.25

Service Code	CPT J9100
Hospital Charge Code	NDG20156
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of CA HMO/PPO	$1.00
Rate for Payer: Cigna of CA HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.92

CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]

Facility

$42.16

Service Code	CPT J0850
Hospital Charge Code	1758636
Hospital Revenue Code	636
Min. Negotiated Rate	$23.19
Max. Negotiated Rate	$31.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.33
Rate for Payer: Aetna of CA Government/Medicare	$21.33
Rate for Payer: Aetna of CA Government/Medicare	$25.30
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$18.97
Rate for Payer: Health Smart Auto/Commercial	$25.30
Rate for Payer: Health Smart Auto/Commercial	$21.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.33
Rate for Payer: LLUH Dept of Risk Management WC	$19.55
Rate for Payer: LLUH Dept of Risk Management WC	$23.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.62

CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION [14634]

Facility

$35.55

Service Code	CPT J0850
Hospital Charge Code	1758636
Hospital Revenue Code	636
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$28.44
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$18.97
Rate for Payer: Cigna of CA HMO/PPO	$28.44
Rate for Payer: Cigna of CA HMO/PPO	$33.73
Rate for Payer: Health Smart Auto/Commercial	$25.30
Rate for Payer: Health Smart Auto/Commercial	$21.33
Rate for Payer: LLUH Dept of Risk Management WC	$23.19
Rate for Payer: LLUH Dept of Risk Management WC	$19.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.66

DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]

Facility

$3.97

Service Code	NDC 0597-0108-54
Hospital Charge Code	ERX212609
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$1.79
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]

Facility

$3.97

Service Code	NDC 0597-0108-54
Hospital Charge Code	ERX212609
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cigna of CA HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-82
Hospital Charge Code	1712463
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cigna of CA HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-55
Hospital Charge Code	1712463
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$1.79
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-55
Hospital Charge Code	1712463
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cigna of CA HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-82
Hospital Charge Code	1712463
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$1.79
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$3.97

Service Code	NDC 0597-0355-56
Hospital Charge Code	1712462
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cigna of CA HMO/PPO	$3.18
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$3.97

Service Code	NDC 0597-0355-56
Hospital Charge Code	1712462
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Cash Price	$1.79
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.98

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$13.04

Service Code	CPT J9130
Hospital Charge Code	1720153
Hospital Revenue Code	636
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$10.43
Rate for Payer: Cash Price	$5.87
Rate for Payer: Cigna of CA HMO/PPO	$10.43
Rate for Payer: Health Smart Auto/Commercial	$7.82
Rate for Payer: LLUH Dept of Risk Management WC	$7.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.78

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$13.04

Service Code	CPT J9130
Hospital Charge Code	1720153
Hospital Revenue Code	636
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$9.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.82
Rate for Payer: Aetna of CA Government/Medicare	$7.82
Rate for Payer: Cash Price	$5.87
Rate for Payer: Health Smart Auto/Commercial	$7.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.82
Rate for Payer: LLUH Dept of Risk Management WC	$7.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.78

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$14.40

Service Code	CPT J9130
Hospital Charge Code	1755114
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$10.80
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	$6.48
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 Beech St/Commercial/PHCS	$10.80

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$14.40

Service Code	CPT J9130
Hospital Charge Code	1755114
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$11.52
Rate for Payer: Cash Price	$6.48
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$10.80

DACOMITINIB 15 MG TABLET [222938]

Facility

$622.49

Service Code	NDC 0069-0197-30
Hospital Charge Code	ERX222938
Hospital Revenue Code	259
Min. Negotiated Rate	$342.37
Max. Negotiated Rate	$497.99
Rate for Payer: Cash Price	$280.12
Rate for Payer: Cigna of CA HMO/PPO	$497.99
Rate for Payer: Health Smart Auto/Commercial	$373.49
Rate for Payer: LLUH Dept of Risk Management WC	$342.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$466.87

DACOMITINIB 15 MG TABLET [222938]

Facility

$622.49

Service Code	NDC 0069-0197-30
Hospital Charge Code	ERX222938
Hospital Revenue Code	259
Min. Negotiated Rate	$342.37
Max. Negotiated Rate	$466.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$373.49
Rate for Payer: Aetna of CA Government/Medicare	$373.49
Rate for Payer: Cash Price	$280.12
Rate for Payer: Health Smart Auto/Commercial	$373.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$373.49
Rate for Payer: LLUH Dept of Risk Management WC	$342.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$466.87

DACOMITINIB 30 MG TABLET [222939]

Facility

$622.49

Service Code	NDC 0069-1198-30
Hospital Charge Code	ERX222939
Hospital Revenue Code	259
Min. Negotiated Rate	$342.37
Max. Negotiated Rate	$466.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$373.49
Rate for Payer: Aetna of CA Government/Medicare	$373.49
Rate for Payer: Cash Price	$280.12
Rate for Payer: Health Smart Auto/Commercial	$373.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$373.49
Rate for Payer: LLUH Dept of Risk Management WC	$342.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$466.87

DACOMITINIB 30 MG TABLET [222939]

Facility

$622.49

Service Code	NDC 0069-1198-30
Hospital Charge Code	ERX222939
Hospital Revenue Code	259
Min. Negotiated Rate	$342.37
Max. Negotiated Rate	$497.99
Rate for Payer: Cash Price	$280.12
Rate for Payer: Cigna of CA HMO/PPO	$497.99
Rate for Payer: Health Smart Auto/Commercial	$373.49
Rate for Payer: LLUH Dept of Risk Management WC	$342.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$466.87

DACOMITINIB 45 MG TABLET [222940]

Facility

$622.49

Service Code	NDC 0069-2299-30
Hospital Charge Code	ERX222940
Hospital Revenue Code	259
Min. Negotiated Rate	$342.37
Max. Negotiated Rate	$466.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$373.49
Rate for Payer: Aetna of CA Government/Medicare	$373.49
Rate for Payer: Cash Price	$280.12
Rate for Payer: Health Smart Auto/Commercial	$373.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$373.49
Rate for Payer: LLUH Dept of Risk Management WC	$342.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$466.87

DACOMITINIB 45 MG TABLET [222940]

Facility

$622.49

Service Code	NDC 0069-2299-30
Hospital Charge Code	ERX222940
Hospital Revenue Code	259
Min. Negotiated Rate	$342.37
Max. Negotiated Rate	$497.99
Rate for Payer: Cash Price	$280.12
Rate for Payer: Cigna of CA HMO/PPO	$497.99
Rate for Payer: Health Smart Auto/Commercial	$373.49
Rate for Payer: LLUH Dept of Risk Management WC	$342.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$466.87

DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]

Facility

$885.00

Service Code	CPT J9120
Hospital Charge Code	1755120
Hospital Revenue Code	636
Min. Negotiated Rate	$486.75
Max. Negotiated Rate	$708.00
Rate for Payer: Cash Price	$398.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$663.75

DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION [28912]

Facility

$885.00

Service Code	CPT J9120
Hospital Charge Code	1755120
Hospital Revenue Code	636
Min. Negotiated Rate	$486.75
Max. Negotiated Rate	$663.75
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	$398.25
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 Beech St/Commercial/PHCS	$663.75

DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [206124]

Facility

$2,072.77

Service Code	CPT J0875
Hospital Charge Code	ERX206124
Hospital Revenue Code	636
Min. Negotiated Rate	$1,140.02
Max. Negotiated Rate	$1,658.22
Rate for Payer: Cash Price	$932.75
Rate for Payer: Cigna of CA HMO/PPO	$1,658.22
Rate for Payer: Health Smart Auto/Commercial	$1,243.66
Rate for Payer: LLUH Dept of Risk Management WC	$1,140.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,554.58

Know your out-of-pocket cost for care.

All Charges