Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$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

DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]

Facility

$479.52

Service Code	NDC 68727-800-02
Hospital Charge Code	NDG4081463
Hospital Revenue Code	636
Min. Negotiated Rate	$263.74
Max. Negotiated Rate	$383.62
Rate for Payer: Cash Price	$215.78
Rate for Payer: Cigna of CA HMO/PPO	$383.62
Rate for Payer: Health Smart Auto/Commercial	$287.71
Rate for Payer: LLUH Dept of Risk Management WC	$263.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$359.64

DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]

Facility

$479.52

Service Code	NDC 68727-800-01
Hospital Charge Code	NDG4081463
Hospital Revenue Code	636
Min. Negotiated Rate	$263.74
Max. Negotiated Rate	$359.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$287.71
Rate for Payer: Aetna of CA Government/Medicare	$287.71
Rate for Payer: Cash Price	$215.78
Rate for Payer: Health Smart Auto/Commercial	$287.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$287.71
Rate for Payer: LLUH Dept of Risk Management WC	$263.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$359.64

DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]

Facility

$479.52

Service Code	NDC 68727-800-02
Hospital Charge Code	NDG4081463
Hospital Revenue Code	636
Min. Negotiated Rate	$263.74
Max. Negotiated Rate	$359.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$287.71
Rate for Payer: Aetna of CA Government/Medicare	$287.71
Rate for Payer: Cash Price	$215.78
Rate for Payer: Health Smart Auto/Commercial	$287.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$287.71
Rate for Payer: LLUH Dept of Risk Management WC	$263.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$359.64

DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]

Facility

$479.52

Service Code	NDC 68727-800-01
Hospital Charge Code	NDG4081463
Hospital Revenue Code	636
Min. Negotiated Rate	$263.74
Max. Negotiated Rate	$383.62
Rate for Payer: Cash Price	$215.78
Rate for Payer: Cigna of CA HMO/PPO	$383.62
Rate for Payer: Health Smart Auto/Commercial	$287.71
Rate for Payer: LLUH Dept of Risk Management WC	$263.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$359.64

DEMECLOCYCLINE 150 MG TABLET [9726]

Facility

$8.32

Service Code	NDC 62584-159-11
Hospital Charge Code	1711453
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.99
Rate for Payer: Aetna of CA Government/Medicare	$4.99
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Smart Auto/Commercial	$4.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.99
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.24

DEMECLOCYCLINE 150 MG TABLET [9726]

Facility

$8.32

Service Code	NDC 62584-159-01
Hospital Charge Code	1711453
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.99
Rate for Payer: Aetna of CA Government/Medicare	$4.99
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Smart Auto/Commercial	$4.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.99
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.24

DEMECLOCYCLINE 150 MG TABLET [9726]

Facility

$8.32

Service Code	NDC 62584-159-01
Hospital Charge Code	1711453
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.66
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cigna of CA HMO/PPO	$6.66
Rate for Payer: Health Smart Auto/Commercial	$4.99
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.24

DEMECLOCYCLINE 150 MG TABLET [9726]

Facility

$8.32

Service Code	NDC 62584-159-11
Hospital Charge Code	1711453
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.66
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cigna of CA HMO/PPO	$6.66
Rate for Payer: Health Smart Auto/Commercial	$4.99
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.24

DEMECLOCYCLINE 300 MG TABLET [9727]

Facility

$15.13

Service Code	NDC 62584-163-11
Hospital Charge Code	1710010
Hospital Revenue Code	259
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$12.10
Rate for Payer: Cash Price	$6.81
Rate for Payer: Cigna of CA HMO/PPO	$12.10
Rate for Payer: Health Smart Auto/Commercial	$9.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.35

DEMECLOCYCLINE 300 MG TABLET [9727]

Facility

$15.13

Service Code	NDC 62584-163-11
Hospital Charge Code	1710010
Hospital Revenue Code	259
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$11.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.08
Rate for Payer: Aetna of CA Government/Medicare	$9.08
Rate for Payer: Cash Price	$6.81
Rate for Payer: Health Smart Auto/Commercial	$9.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.08
Rate for Payer: LLUH Dept of Risk Management WC	$8.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.35

DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [106804]

Facility

$2,109.35

Service Code	CPT J0897
Hospital Charge Code	1755765
Hospital Revenue Code	636
Min. Negotiated Rate	$1,160.14
Max. Negotiated Rate	$1,582.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,265.61
Rate for Payer: Aetna of CA Government/Medicare	$1,265.61
Rate for Payer: Cash Price	$949.21
Rate for Payer: Health Smart Auto/Commercial	$1,265.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,265.61
Rate for Payer: LLUH Dept of Risk Management WC	$1,160.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,582.01

DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [106804]

Facility

$2,109.35

Service Code	CPT J0897
Hospital Charge Code	1755765
Hospital Revenue Code	636
Min. Negotiated Rate	$1,160.14
Max. Negotiated Rate	$1,687.48
Rate for Payer: Cash Price	$949.21
Rate for Payer: Cigna of CA HMO/PPO	$1,687.48
Rate for Payer: Health Smart Auto/Commercial	$1,265.61
Rate for Payer: LLUH Dept of Risk Management WC	$1,160.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,582.01

DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]

Facility

$1,949.45

Service Code	CPT J0897
Hospital Charge Code	1755797
Hospital Revenue Code	636
Min. Negotiated Rate	$1,072.20
Max. Negotiated Rate	$1,462.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,169.67
Rate for Payer: Aetna of CA Government/Medicare	$1,169.67
Rate for Payer: Cash Price	$877.25
Rate for Payer: Health Smart Auto/Commercial	$1,169.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,169.67
Rate for Payer: LLUH Dept of Risk Management WC	$1,072.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,462.09

DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [105502]

Facility

$1,949.45

Service Code	CPT J0897
Hospital Charge Code	1755797
Hospital Revenue Code	636
Min. Negotiated Rate	$1,072.20
Max. Negotiated Rate	$1,559.56
Rate for Payer: Cash Price	$877.25
Rate for Payer: Cigna of CA HMO/PPO	$1,559.56
Rate for Payer: Health Smart Auto/Commercial	$1,169.67
Rate for Payer: LLUH Dept of Risk Management WC	$1,072.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,462.09

DESIPRAMINE 25 MG TABLET [2286]

Facility

$1.35

Service Code	NDC 45963-342-02
Hospital Charge Code	1710265
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.08
Rate for Payer: Cash Price	$0.61
Rate for Payer: Cigna of CA HMO/PPO	$1.08
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.01

DESIPRAMINE 25 MG TABLET [2286]

Facility

$1.35

Service Code	NDC 45963-342-02
Hospital Charge Code	1710265
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.81
Rate for Payer: Aetna of CA Government/Medicare	$0.81
Rate for Payer: Cash Price	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.81
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.01

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$0.88

Service Code	NDC 60505-0257-1
Hospital Charge Code	1711734
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.66

DESMOPRESSIN 0.1 MG TABLET [16052]

Facility

$0.88

Service Code	NDC 60505-0257-1
Hospital Charge Code	1711734
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.66

DESMOPRESSIN 0.2 MG TABLET [16053]

Facility

$0.99

Service Code	NDC 60505-0258-1
Hospital Charge Code	1711735
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.74

DESMOPRESSIN 0.2 MG TABLET [16053]

Facility

$0.99

Service Code	NDC 60505-0258-1
Hospital Charge Code	1711735
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.74

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]

Facility

$47.28

Service Code	NDC 24208-342-05
Hospital Charge Code	NDG27770
Hospital Revenue Code	259
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$37.82
Rate for Payer: Cash Price	$21.28
Rate for Payer: Cigna of CA HMO/PPO	$37.82
Rate for Payer: Health Smart Auto/Commercial	$28.37
Rate for Payer: LLUH Dept of Risk Management WC	$26.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.46

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]

Facility

$47.28

Service Code	NDC 24208-342-05
Hospital Charge Code	NDG27770
Hospital Revenue Code	259
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$35.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.37
Rate for Payer: Aetna of CA Government/Medicare	$28.37
Rate for Payer: Cash Price	$21.28
Rate for Payer: Health Smart Auto/Commercial	$28.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.37
Rate for Payer: LLUH Dept of Risk Management WC	$26.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.46

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED) [21135]

Facility

$29.55

Service Code	NDC 47335-788-91
Hospital Charge Code	1740263
Hospital Revenue Code	259
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$22.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.73
Rate for Payer: Aetna of CA Government/Medicare	$17.73
Rate for Payer: Cash Price	$13.30
Rate for Payer: Health Smart Auto/Commercial	$17.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.73
Rate for Payer: LLUH Dept of Risk Management WC	$16.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.16

DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED) [21135]

Facility

$29.55

Service Code	NDC 47335-788-91
Hospital Charge Code	1740263
Hospital Revenue Code	259
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$23.64
Rate for Payer: Cash Price	$13.30
Rate for Payer: Cigna of CA HMO/PPO	$23.64
Rate for Payer: Health Smart Auto/Commercial	$17.73
Rate for Payer: LLUH Dept of Risk Management WC	$16.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.16

Know your out-of-pocket cost for care.

All Charges