Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DASATINIB 70 MG TABLET [76719]

Facility

$382.03

Service Code	NDC 0003-0524-11
Hospital Charge Code	1711974
Hospital Revenue Code	259
Min. Negotiated Rate	$210.12
Max. Negotiated Rate	$305.62
Rate for Payer: Cash Price	$171.91
Rate for Payer: Cigna of CA HMO/PPO	$305.62
Rate for Payer: Health Smart Auto/Commercial	$229.22
Rate for Payer: LLUH Dept of Risk Management WC	$210.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$286.52

DASATINIB 70 MG TABLET [76719]

Facility

$382.03

Service Code	NDC 0003-0524-11
Hospital Charge Code	1711974
Hospital Revenue Code	259
Min. Negotiated Rate	$210.12
Max. Negotiated Rate	$286.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$229.22
Rate for Payer: Aetna of CA Government/Medicare	$229.22
Rate for Payer: Cash Price	$171.91
Rate for Payer: Health Smart Auto/Commercial	$229.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$229.22
Rate for Payer: LLUH Dept of Risk Management WC	$210.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$286.52

DASATINIB 80 MG TABLET [108421]

Facility

$688.54

Service Code	NDC 0003-0855-22
Hospital Charge Code	1712500
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 80 MG TABLET [108421]

Facility

$688.54

Service Code	NDC 0003-0855-22
Hospital Charge Code	1712500
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

DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]

Facility

$11,772.00

Service Code	CPT J9153
Hospital Charge Code	ERX219514
Hospital Revenue Code	636
Min. Negotiated Rate	$6,474.60
Max. Negotiated Rate	$8,829.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7,063.20
Rate for Payer: Aetna of CA Government/Medicare	$7,063.20
Rate for Payer: Cash Price	$5,297.40
Rate for Payer: Health Smart Auto/Commercial	$7,063.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7,063.20
Rate for Payer: LLUH Dept of Risk Management WC	$6,474.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8,829.00

DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]

Facility

$11,772.00

Service Code	CPT J9153
Hospital Charge Code	ERX219514
Hospital Revenue Code	636
Min. Negotiated Rate	$6,474.60
Max. Negotiated Rate	$9,417.60
Rate for Payer: Health Smart Auto/Commercial	$7,063.20
Rate for Payer: Cash Price	$5,297.40
Rate for Payer: Cigna of CA HMO/PPO	$9,417.60
Rate for Payer: LLUH Dept of Risk Management WC	$6,474.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8,829.00

DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]

Facility

$39.34

Service Code	CPT J9150
Hospital Charge Code	1755125
Hospital Revenue Code	636
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$29.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.60
Rate for Payer: Aetna of CA Government/Medicare	$23.60
Rate for Payer: Cash Price	$17.70
Rate for Payer: Health Smart Auto/Commercial	$23.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.60
Rate for Payer: LLUH Dept of Risk Management WC	$21.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.50

DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]

Facility

$39.34

Service Code	CPT J9150
Hospital Charge Code	1755125
Hospital Revenue Code	636
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$31.47
Rate for Payer: Cash Price	$17.70
Rate for Payer: Cigna of CA HMO/PPO	$31.47
Rate for Payer: Health Smart Auto/Commercial	$23.60
Rate for Payer: LLUH Dept of Risk Management WC	$21.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.50

DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]

Facility

$1,943.95

Service Code	NDC 64842-0727-9
Hospital Revenue Code	259
Min. Negotiated Rate	$1,069.17
Max. Negotiated Rate	$1,457.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,166.37
Rate for Payer: Aetna of CA Government/Medicare	$1,166.37
Rate for Payer: Cash Price	$874.78
Rate for Payer: Health Smart Auto/Commercial	$1,166.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,166.37
Rate for Payer: LLUH Dept of Risk Management WC	$1,069.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,457.96

DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]

Facility

$1,943.95

Service Code	NDC 64842-0727-9
Hospital Revenue Code	259
Min. Negotiated Rate	$1,069.17
Max. Negotiated Rate	$1,555.16
Rate for Payer: Cash Price	$874.78
Rate for Payer: Cigna of CA HMO/PPO	$1,555.16
Rate for Payer: Health Smart Auto/Commercial	$1,166.37
Rate for Payer: LLUH Dept of Risk Management WC	$1,069.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,457.96

DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]

Facility

$240.00

Service Code	CPT J0894
Hospital Charge Code	1755761
Hospital Revenue Code	636
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$144.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$432.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$142.56
Rate for Payer: Aetna of CA Government/Medicare	$142.56
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$144.00
Rate for Payer: Aetna of CA Government/Medicare	$432.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$106.92
Rate for Payer: Cash Price	$324.00
Rate for Payer: Health Smart Auto/Commercial	$142.56
Rate for Payer: Health Smart Auto/Commercial	$432.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$432.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$144.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$142.56
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: LLUH Dept of Risk Management WC	$130.68
Rate for Payer: LLUH Dept of Risk Management WC	$396.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$540.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$180.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$178.20

DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]

Facility

$240.00

Service Code	CPT J0894
Hospital Charge Code	1755761
Hospital Revenue Code	636
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$192.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$106.92
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna of CA HMO/PPO	$190.08
Rate for Payer: Cigna of CA HMO/PPO	$576.00
Rate for Payer: Cigna of CA HMO/PPO	$192.00
Rate for Payer: Cigna of CA HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$142.56
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Health Smart Auto/Commercial	$432.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: LLUH Dept of Risk Management WC	$396.00
Rate for Payer: LLUH Dept of Risk Management WC	$130.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$540.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$180.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$178.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00

DEFERASIROX 180 MG TABLET [206427]

Facility

$116.95

Service Code	NDC 0078-0655-15
Hospital Charge Code	ERX206427
Hospital Revenue Code	259
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$93.56
Rate for Payer: Cash Price	$52.63
Rate for Payer: Cigna of CA HMO/PPO	$93.56
Rate for Payer: Health Smart Auto/Commercial	$70.17
Rate for Payer: LLUH Dept of Risk Management WC	$64.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.71

DEFERASIROX 180 MG TABLET [206427]

Facility

$116.95

Service Code	NDC 0078-0655-15
Hospital Charge Code	ERX206427
Hospital Revenue Code	259
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$87.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.17
Rate for Payer: Aetna of CA Government/Medicare	$70.17
Rate for Payer: Cash Price	$52.63
Rate for Payer: Health Smart Auto/Commercial	$70.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.17
Rate for Payer: LLUH Dept of Risk Management WC	$64.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.71

DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]

Facility

$116.95

Service Code	NDC 0078-0469-15
Hospital Charge Code	1712350
Hospital Revenue Code	259
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$87.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.17
Rate for Payer: Aetna of CA Government/Medicare	$70.17
Rate for Payer: Cash Price	$52.63
Rate for Payer: Health Smart Auto/Commercial	$70.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.17
Rate for Payer: LLUH Dept of Risk Management WC	$64.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.71

DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]

Facility

$60.08

Service Code	NDC 45963-455-30
Hospital Charge Code	1712350
Hospital Revenue Code	259
Min. Negotiated Rate	$33.04
Max. Negotiated Rate	$48.06
Rate for Payer: Cash Price	$27.04
Rate for Payer: Cigna of CA HMO/PPO	$48.06
Rate for Payer: Health Smart Auto/Commercial	$36.05
Rate for Payer: LLUH Dept of Risk Management WC	$33.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.06

DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]

Facility

$60.08

Service Code	NDC 45963-455-30
Hospital Charge Code	1712350
Hospital Revenue Code	259
Min. Negotiated Rate	$33.04
Max. Negotiated Rate	$45.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.05
Rate for Payer: Aetna of CA Government/Medicare	$36.05
Rate for Payer: Cash Price	$27.04
Rate for Payer: Health Smart Auto/Commercial	$36.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.05
Rate for Payer: LLUH Dept of Risk Management WC	$33.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.06

DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]

Facility

$116.95

Service Code	NDC 0078-0469-15
Hospital Charge Code	1712350
Hospital Revenue Code	259
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$93.56
Rate for Payer: Cash Price	$52.63
Rate for Payer: Cigna of CA HMO/PPO	$93.56
Rate for Payer: Health Smart Auto/Commercial	$70.17
Rate for Payer: LLUH Dept of Risk Management WC	$64.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.71

DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]

Facility

$233.89

Service Code	NDC 0078-0470-15
Hospital Charge Code	1712351
Hospital Revenue Code	259
Min. Negotiated Rate	$128.64
Max. Negotiated Rate	$175.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$140.33
Rate for Payer: Aetna of CA Government/Medicare	$140.33
Rate for Payer: Cash Price	$105.25
Rate for Payer: Health Smart Auto/Commercial	$140.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$140.33
Rate for Payer: LLUH Dept of Risk Management WC	$128.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$175.42

DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]

Facility

$233.89

Service Code	NDC 0078-0470-15
Hospital Charge Code	1712351
Hospital Revenue Code	259
Min. Negotiated Rate	$128.64
Max. Negotiated Rate	$187.11
Rate for Payer: Cash Price	$105.25
Rate for Payer: Cigna of CA HMO/PPO	$187.11
Rate for Payer: Health Smart Auto/Commercial	$140.33
Rate for Payer: LLUH Dept of Risk Management WC	$128.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$175.42

DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]

Facility

$49.44

Service Code	CPT J0895
Hospital Charge Code	1712428
Hospital Revenue Code	636
Min. Negotiated Rate	$27.19
Max. Negotiated Rate	$37.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.66
Rate for Payer: Aetna of CA Government/Medicare	$29.66
Rate for Payer: Cash Price	$22.25
Rate for Payer: Health Smart Auto/Commercial	$29.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.66
Rate for Payer: LLUH Dept of Risk Management WC	$27.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.08

DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]

Facility

$49.44

Service Code	CPT J0895
Hospital Charge Code	1712428
Hospital Revenue Code	636
Min. Negotiated Rate	$27.19
Max. Negotiated Rate	$39.55
Rate for Payer: Cash Price	$22.25
Rate for Payer: Cigna of CA HMO/PPO	$39.55
Rate for Payer: Health Smart Auto/Commercial	$29.66
Rate for Payer: LLUH Dept of Risk Management WC	$27.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.08

DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]

Facility

$15.54

Service Code	CPT J0895
Hospital Revenue Code	636
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$12.43
Rate for Payer: Cash Price	$6.99
Rate for Payer: Cigna of CA HMO/PPO	$12.43
Rate for Payer: Health Smart Auto/Commercial	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$8.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.66

DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]

Facility

$15.54

Service Code	CPT J0895
Hospital Revenue Code	636
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$11.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.32
Rate for Payer: Aetna of CA Government/Medicare	$9.32
Rate for Payer: Cash Price	$6.99
Rate for Payer: Health Smart Auto/Commercial	$9.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$8.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.66

DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]

Facility

$15.54

Service Code	CPT J0895
Hospital Charge Code	1720046
Hospital Revenue Code	636
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$11.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.32
Rate for Payer: Aetna of CA Government/Medicare	$9.32
Rate for Payer: Cash Price	$6.99
Rate for Payer: Health Smart Auto/Commercial	$9.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$8.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.66

Know your out-of-pocket cost for care.

All Charges