Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

DARBEPOETIN ALFA 150 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108046]

Facility

$4,644.00

Service Code	CPT J0881
Hospital Charge Code	1720973
Hospital Revenue Code	636
Min. Negotiated Rate	$2,554.20
Max. Negotiated Rate	$3,715.20
Rate for Payer: Cash Price	$2,089.80
Rate for Payer: Cigna of CA HMO/PPO	$3,715.20
Rate for Payer: Health Smart Auto/Commercial	$2,786.40
Rate for Payer: LLUH Dept of Risk Management WC	$2,554.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,483.00

DARBEPOETIN ALFA 150 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108046]

Facility

$4,644.00

Service Code	CPT J0881
Hospital Charge Code	1720973
Hospital Revenue Code	636
Min. Negotiated Rate	$2,554.20
Max. Negotiated Rate	$3,483.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,786.40
Rate for Payer: Aetna of CA Government/Medicare	$2,786.40
Rate for Payer: Cash Price	$2,089.80
Rate for Payer: Health Smart Auto/Commercial	$2,786.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,786.40
Rate for Payer: LLUH Dept of Risk Management WC	$2,554.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,483.00

DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]

Facility

$552.86

Service Code	CPT J0881
Hospital Charge Code	1720969
Hospital Revenue Code	636
Min. Negotiated Rate	$304.07
Max. Negotiated Rate	$442.29
Rate for Payer: Cash Price	$248.79
Rate for Payer: Cigna of CA HMO/PPO	$442.29
Rate for Payer: Health Smart Auto/Commercial	$331.72
Rate for Payer: LLUH Dept of Risk Management WC	$304.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$414.64

DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE [108041]

Facility

$552.86

Service Code	CPT J0881
Hospital Charge Code	1720969
Hospital Revenue Code	636
Min. Negotiated Rate	$304.07
Max. Negotiated Rate	$414.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$331.72
Rate for Payer: Aetna of CA Government/Medicare	$331.72
Rate for Payer: Cash Price	$248.79
Rate for Payer: Health Smart Auto/Commercial	$331.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$331.72
Rate for Payer: LLUH Dept of Risk Management WC	$304.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$414.64

DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]

Facility

$928.80

Service Code	CPT J0881
Hospital Charge Code	1720970
Hospital Revenue Code	636
Min. Negotiated Rate	$510.84
Max. Negotiated Rate	$696.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$557.28
Rate for Payer: Aetna of CA Government/Medicare	$557.28
Rate for Payer: Cash Price	$417.96
Rate for Payer: Health Smart Auto/Commercial	$557.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$557.28
Rate for Payer: LLUH Dept of Risk Management WC	$510.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$696.60

DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [108042]

Facility

$928.80

Service Code	CPT J0881
Hospital Charge Code	1720970
Hospital Revenue Code	636
Min. Negotiated Rate	$510.84
Max. Negotiated Rate	$743.04
Rate for Payer: Cash Price	$417.96
Rate for Payer: Cigna of CA HMO/PPO	$743.04
Rate for Payer: Health Smart Auto/Commercial	$557.28
Rate for Payer: LLUH Dept of Risk Management WC	$510.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$696.60

DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108043]

Facility

$1,857.60

Service Code	CPT J0881
Hospital Charge Code	1720971
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

DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE [108043]

Facility

$1,857.60

Service Code	CPT J0881
Hospital Charge Code	1720971
Hospital Revenue Code	636
Min. Negotiated Rate	$1,021.68
Max. Negotiated Rate	$1,393.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,114.56
Rate for Payer: Aetna of CA Government/Medicare	$1,114.56
Rate for Payer: Cash Price	$835.92
Rate for Payer: Health Smart Auto/Commercial	$1,114.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

DAROLUTAMIDE 300 MG TABLET [225419]

Facility

$128.66

Service Code	NDC 50419-395-01
Hospital Revenue Code	259
Min. Negotiated Rate	$70.76
Max. Negotiated Rate	$96.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$77.20
Rate for Payer: Aetna of CA Government/Medicare	$77.20
Rate for Payer: Cash Price	$57.90
Rate for Payer: Health Smart Auto/Commercial	$77.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$77.20
Rate for Payer: LLUH Dept of Risk Management WC	$70.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$96.50

DAROLUTAMIDE 300 MG TABLET [225419]

Facility

$128.66

Service Code	NDC 50419-395-01
Hospital Revenue Code	259
Min. Negotiated Rate	$70.76
Max. Negotiated Rate	$102.93
Rate for Payer: Cash Price	$57.90
Rate for Payer: Cigna of CA HMO/PPO	$102.93
Rate for Payer: Health Smart Auto/Commercial	$77.20
Rate for Payer: LLUH Dept of Risk Management WC	$70.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$96.50

DARUNAVIR 600 MG TABLET [92851]

Facility

$41.91

Service Code	NDC 59676-562-01
Hospital Charge Code	1712433
Hospital Revenue Code	259
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$31.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.15
Rate for Payer: Aetna of CA Government/Medicare	$25.15
Rate for Payer: Cash Price	$18.86
Rate for Payer: Health Smart Auto/Commercial	$25.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.15
Rate for Payer: LLUH Dept of Risk Management WC	$23.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.43

DARUNAVIR 600 MG TABLET [92851]

Facility

$41.91

Service Code	NDC 59676-562-01
Hospital Charge Code	1712433
Hospital Revenue Code	259
Min. Negotiated Rate	$23.05
Max. Negotiated Rate	$33.53
Rate for Payer: Cash Price	$18.86
Rate for Payer: Cigna of CA HMO/PPO	$33.53
Rate for Payer: Health Smart Auto/Commercial	$25.15
Rate for Payer: LLUH Dept of Risk Management WC	$23.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.43

DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [208697]

Facility

$95.80

Service Code	NDC 59676-575-30
Hospital Charge Code	ERX208697
Hospital Revenue Code	259
Min. Negotiated Rate	$52.69
Max. Negotiated Rate	$76.64
Rate for Payer: Cash Price	$43.11
Rate for Payer: Cigna of CA HMO/PPO	$76.64
Rate for Payer: Health Smart Auto/Commercial	$57.48
Rate for Payer: LLUH Dept of Risk Management WC	$52.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.85

DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET [208697]

Facility

$95.80

Service Code	NDC 59676-575-30
Hospital Charge Code	ERX208697
Hospital Revenue Code	259
Min. Negotiated Rate	$52.69
Max. Negotiated Rate	$71.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.48
Rate for Payer: Aetna of CA Government/Medicare	$57.48
Rate for Payer: Cash Price	$43.11
Rate for Payer: Health Smart Auto/Commercial	$57.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.48
Rate for Payer: LLUH Dept of Risk Management WC	$52.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.85

DARUNAVIR 800 MG TABLET [199468]

Facility

$83.81

Service Code	NDC 59676-566-30
Hospital Charge Code	1712557
Hospital Revenue Code	259
Min. Negotiated Rate	$46.10
Max. Negotiated Rate	$67.05
Rate for Payer: Cash Price	$37.71
Rate for Payer: Cigna of CA HMO/PPO	$67.05
Rate for Payer: Health Smart Auto/Commercial	$50.29
Rate for Payer: LLUH Dept of Risk Management WC	$46.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$62.86

DARUNAVIR 800 MG TABLET [199468]

Facility

$72.41

Service Code	NDC 68180-346-06
Hospital Charge Code	1712557
Hospital Revenue Code	259
Min. Negotiated Rate	$39.83
Max. Negotiated Rate	$57.93
Rate for Payer: Cash Price	$32.58
Rate for Payer: Cigna of CA HMO/PPO	$57.93
Rate for Payer: Health Smart Auto/Commercial	$43.45
Rate for Payer: LLUH Dept of Risk Management WC	$39.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.31

DARUNAVIR 800 MG TABLET [199468]

Facility

$72.41

Service Code	NDC 68180-346-06
Hospital Charge Code	1712557
Hospital Revenue Code	259
Min. Negotiated Rate	$39.83
Max. Negotiated Rate	$54.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.45
Rate for Payer: Aetna of CA Government/Medicare	$43.45
Rate for Payer: Cash Price	$32.58
Rate for Payer: Health Smart Auto/Commercial	$43.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.45
Rate for Payer: LLUH Dept of Risk Management WC	$39.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.31

DARUNAVIR 800 MG TABLET [199468]

Facility

$83.81

Service Code	NDC 59676-566-30
Hospital Charge Code	1712557
Hospital Revenue Code	259
Min. Negotiated Rate	$46.10
Max. Negotiated Rate	$62.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.29
Rate for Payer: Aetna of CA Government/Medicare	$50.29
Rate for Payer: Cash Price	$37.71
Rate for Payer: Health Smart Auto/Commercial	$50.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.29
Rate for Payer: LLUH Dept of Risk Management WC	$46.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$62.86

DASATINIB 100 MG TABLET [92897]

Facility

$688.54

Service Code	NDC 0003-0852-22
Hospital Charge Code	1712498
Hospital Revenue Code	259
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$550.83
Rate for Payer: Cash Price	$309.84
Rate for Payer: Cigna of CA HMO/PPO	$550.83
Rate for Payer: Health Smart Auto/Commercial	$413.12
Rate for Payer: LLUH Dept of Risk Management WC	$378.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$516.40

DASATINIB 100 MG TABLET [92897]

Facility

$688.54

Service Code	NDC 0003-0852-22
Hospital Charge Code	1712498
Hospital Revenue Code	259
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$516.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$413.12
Rate for Payer: Aetna of CA Government/Medicare	$413.12
Rate for Payer: Cash Price	$309.84
Rate for Payer: Health Smart Auto/Commercial	$413.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$413.12
Rate for Payer: LLUH Dept of Risk Management WC	$378.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$516.40

DASATINIB 140 MG TABLET [108422]

Facility

$688.54

Service Code	NDC 0003-0857-22
Hospital Charge Code	1712499
Hospital Revenue Code	259
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$516.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$413.12
Rate for Payer: Aetna of CA Government/Medicare	$413.12
Rate for Payer: Cash Price	$309.84
Rate for Payer: Health Smart Auto/Commercial	$413.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$413.12
Rate for Payer: LLUH Dept of Risk Management WC	$378.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$516.40

DASATINIB 140 MG TABLET [108422]

Facility

$688.54

Service Code	NDC 0003-0857-22
Hospital Charge Code	1712499
Hospital Revenue Code	259
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$550.83
Rate for Payer: Cash Price	$309.84
Rate for Payer: Cigna of CA HMO/PPO	$550.83
Rate for Payer: Health Smart Auto/Commercial	$413.12
Rate for Payer: LLUH Dept of Risk Management WC	$378.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$516.40

DASATINIB 20 MG TABLET [76717]

Facility

$191.01

Service Code	NDC 0003-0527-11
Hospital Charge Code	1711976
Hospital Revenue Code	259
Min. Negotiated Rate	$105.06
Max. Negotiated Rate	$143.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$114.61
Rate for Payer: Aetna of CA Government/Medicare	$114.61
Rate for Payer: Cash Price	$85.95
Rate for Payer: Health Smart Auto/Commercial	$114.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$114.61
Rate for Payer: LLUH Dept of Risk Management WC	$105.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$143.26

DASATINIB 20 MG TABLET [76717]

Facility

$191.01

Service Code	NDC 0003-0527-11
Hospital Charge Code	1711976
Hospital Revenue Code	259
Min. Negotiated Rate	$105.06
Max. Negotiated Rate	$152.81
Rate for Payer: Cash Price	$85.95
Rate for Payer: Cigna of CA HMO/PPO	$152.81
Rate for Payer: Health Smart Auto/Commercial	$114.61
Rate for Payer: LLUH Dept of Risk Management WC	$105.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$143.26

Know your out-of-pocket cost for care.

All Charges