Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]

Facility

$0.11

Service Code	NDC 9994-0802-62
Hospital Charge Code	1715985
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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	$0.05
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 Beech St/Commercial/PHCS	$0.08

DANTROLENE ORAL SUSPENSION COMPOUND 5 MG/ML [4080262]

Facility

$0.11

Service Code	NDC 9994-0802-62
Hospital Charge Code	1715985
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]

Facility

$22.61

Service Code	NDC 0310-6210-30
Hospital Charge Code	ERX204693
Hospital Revenue Code	259
Min. Negotiated Rate	$12.44
Max. Negotiated Rate	$16.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.57
Rate for Payer: Aetna of CA Government/Medicare	$13.57
Rate for Payer: Cash Price	$10.17
Rate for Payer: Health Smart Auto/Commercial	$13.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.57
Rate for Payer: LLUH Dept of Risk Management WC	$12.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.96

DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [204693]

Facility

$22.61

Service Code	NDC 0310-6210-30
Hospital Charge Code	ERX204693
Hospital Revenue Code	259
Min. Negotiated Rate	$12.44
Max. Negotiated Rate	$18.09
Rate for Payer: Health Smart Auto/Commercial	$13.57
Rate for Payer: Cash Price	$10.17
Rate for Payer: Cigna of CA HMO/PPO	$18.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.96

DAPSONE 100 MG TABLET [2131]

Facility

$1.45

Service Code	NDC 70954-136-10
Hospital Charge Code	1711546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.09

DAPSONE 100 MG TABLET [2131]

Facility

$1.45

Service Code	NDC 70954-136-10
Hospital Charge Code	1711546
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.09
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	$0.65
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 Beech St/Commercial/PHCS	$1.09

DAPSONE 25 MG TABLET [2132]

Facility

$2.37

Service Code	NDC 13925-504-30
Hospital Charge Code	1711606
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.78

DAPSONE 25 MG TABLET [2132]

Facility

$1.18

Service Code	NDC 69543-150-30
Hospital Charge Code	1711606
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

DAPSONE 25 MG TABLET [2132]

Facility

$2.74

Service Code	NDC 49938-102-30
Hospital Charge Code	1711606
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.06
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	$1.23
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 Beech St/Commercial/PHCS	$2.06

DAPSONE 25 MG TABLET [2132]

Facility

$2.74

Service Code	NDC 49938-102-30
Hospital Charge Code	1711606
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.19
Rate for Payer: Cash Price	$1.23
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.06

DAPSONE 25 MG TABLET [2132]

Facility

$2.37

Service Code	NDC 13925-504-30
Hospital Charge Code	1711606
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.78
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	$1.07
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 Beech St/Commercial/PHCS	$1.78

DAPSONE 25 MG TABLET [2132]

Facility

$1.18

Service Code	NDC 69543-150-30
Hospital Charge Code	1711606
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]

Facility

$2.37

Service Code	NDC 9994-0802-63
Hospital Charge Code	1715000
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.78
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	$1.07
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 Beech St/Commercial/PHCS	$1.78

DAPSONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080263]

Facility

$2.37

Service Code	NDC 9994-0802-63
Hospital Charge Code	1715000
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.78

DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]

Facility

$42.00

Service Code	CPT J0878
Hospital Charge Code	1720999
Hospital Revenue Code	636
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$25.20
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$54.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.50

DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]

Facility

$42.00

Service Code	CPT J0878
Hospital Charge Code	1720999
Hospital Revenue Code	636
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.60
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna of CA HMO/PPO	$33.60
Rate for Payer: Cigna of CA HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.50

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

Facility

$729.49

Service Code	CPT J9144
Hospital Charge Code	NDG228045
Hospital Revenue Code	636
Min. Negotiated Rate	$401.22
Max. Negotiated Rate	$547.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$437.69
Rate for Payer: Aetna of CA Government/Medicare	$437.69
Rate for Payer: Cash Price	$328.27
Rate for Payer: Health Smart Auto/Commercial	$437.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$437.69
Rate for Payer: LLUH Dept of Risk Management WC	$401.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$547.12

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

Facility

$729.49

Service Code	CPT J9144
Hospital Charge Code	NDG228045
Hospital Revenue Code	636
Min. Negotiated Rate	$401.22
Max. Negotiated Rate	$583.59
Rate for Payer: Cash Price	$328.27
Rate for Payer: Cigna of CA HMO/PPO	$583.59
Rate for Payer: Health Smart Auto/Commercial	$437.69
Rate for Payer: LLUH Dept of Risk Management WC	$401.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$547.12

DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION [211862]

Facility

$160.56

Service Code	NDC 57894-502-05
Hospital Charge Code	NDG211862B
Hospital Revenue Code	636
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$128.45
Rate for Payer: Cash Price	$72.25
Rate for Payer: Cigna of CA HMO/PPO	$128.45
Rate for Payer: Health Smart Auto/Commercial	$96.34
Rate for Payer: LLUH Dept of Risk Management WC	$88.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.42

DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION [211862]

Facility

$160.56

Service Code	NDC 57894-502-20
Hospital Charge Code	NDG211862
Hospital Revenue Code	636
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$128.45
Rate for Payer: Cash Price	$72.25
Rate for Payer: Cigna of CA HMO/PPO	$128.45
Rate for Payer: Health Smart Auto/Commercial	$96.34
Rate for Payer: LLUH Dept of Risk Management WC	$88.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.42

DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION [211862]

Facility

$160.56

Service Code	NDC 57894-502-20
Hospital Charge Code	NDG211862
Hospital Revenue Code	636
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$120.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.34
Rate for Payer: Aetna of CA Government/Medicare	$96.34
Rate for Payer: Cash Price	$72.25
Rate for Payer: Health Smart Auto/Commercial	$96.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$96.34
Rate for Payer: LLUH Dept of Risk Management WC	$88.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.42

DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION [211862]

Facility

$160.56

Service Code	NDC 57894-502-05
Hospital Charge Code	NDG211862B
Hospital Revenue Code	636
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$120.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.34
Rate for Payer: Aetna of CA Government/Medicare	$96.34
Rate for Payer: Cash Price	$72.25
Rate for Payer: Health Smart Auto/Commercial	$96.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$96.34
Rate for Payer: LLUH Dept of Risk Management WC	$88.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.42

DARATUMUMAB-HYALURONIDASE-FIHJ (DARZALEX FASPRO) 1800 MG/30000 UNIT SQ INJECTION [40820601]

Facility

$729.49

Service Code	CPT J9144
Hospital Charge Code	NDG228045
Hospital Revenue Code	636
Min. Negotiated Rate	$401.22
Max. Negotiated Rate	$547.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$437.69
Rate for Payer: Aetna of CA Government/Medicare	$437.69
Rate for Payer: Cash Price	$328.27
Rate for Payer: Health Smart Auto/Commercial	$437.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$437.69
Rate for Payer: LLUH Dept of Risk Management WC	$401.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$547.12

DARATUMUMAB-HYALURONIDASE-FIHJ (DARZALEX FASPRO) 1800 MG/30000 UNIT SQ INJECTION [40820601]

Facility

$729.49

Service Code	CPT J9144
Hospital Charge Code	NDG228045
Hospital Revenue Code	636
Min. Negotiated Rate	$401.22
Max. Negotiated Rate	$583.59
Rate for Payer: Cash Price	$328.27
Rate for Payer: Cigna of CA HMO/PPO	$583.59
Rate for Payer: Health Smart Auto/Commercial	$437.69
Rate for Payer: LLUH Dept of Risk Management WC	$401.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$547.12

DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE [108044]

Facility

$1,857.60

Service Code	CPT J0881
Hospital Charge Code	1720972
Hospital Revenue Code	636
Min. Negotiated Rate	$1,021.68
Max. Negotiated Rate	$1,486.08
Rate for Payer: Cash Price	$835.92
Rate for Payer: Cigna of CA HMO/PPO	$1,486.08
Rate for Payer: Health Smart Auto/Commercial	$1,114.56
Rate for Payer: LLUH Dept of Risk Management WC	$1,021.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,393.20

Know your out-of-pocket cost for care.

All Charges