Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DESMOPRESSIN 25 MCG 1/4 TAB [4080522]

Facility

$3.02

Service Code	NDC 9994-0805-22
Hospital Charge Code	1712429
Hospital Revenue Code	259
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$2.42
Rate for Payer: Cash Price	$1.36
Rate for Payer: Cigna of CA HMO/PPO	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.26

DESMOPRESSIN 25 MCG 1/4 TAB [4080522]

Facility

$3.02

Service Code	NDC 9994-0805-22
Hospital Charge Code	1712429
Hospital Revenue Code	259
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.81
Rate for Payer: Aetna of CA Government/Medicare	$1.81
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Smart Auto/Commercial	$1.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.26

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$63.00

Service Code	CPT J2597
Hospital Charge Code	1757507
Hospital Revenue Code	636
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$47.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.72
Rate for Payer: Aetna of CA Government/Medicare	$36.72
Rate for Payer: Aetna of CA Government/Medicare	$37.80
Rate for Payer: Cash Price	$28.35
Rate for Payer: Cash Price	$27.54
Rate for Payer: Health Smart Auto/Commercial	$36.72
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.80
Rate for Payer: LLUH Dept of Risk Management WC	$33.66
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.25

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$63.00

Service Code	CPT J2597
Hospital Charge Code	1757507
Hospital Revenue Code	636
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$50.40
Rate for Payer: Cash Price	$28.35
Rate for Payer: Cash Price	$27.54
Rate for Payer: Cigna of CA HMO/PPO	$48.96
Rate for Payer: Cigna of CA HMO/PPO	$50.40
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: Health Smart Auto/Commercial	$36.72
Rate for Payer: LLUH Dept of Risk Management WC	$33.66
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.25

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$63.00

Service Code	CPT J2597
Hospital Charge Code	1720511
Hospital Revenue Code	636
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$50.40
Rate for Payer: Cash Price	$28.35
Rate for Payer: Cash Price	$31.32
Rate for Payer: Cash Price	$32.14
Rate for Payer: Cigna of CA HMO/PPO	$50.40
Rate for Payer: Cigna of CA HMO/PPO	$55.68
Rate for Payer: Cigna of CA HMO/PPO	$57.14
Rate for Payer: Health Smart Auto/Commercial	$42.85
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: Health Smart Auto/Commercial	$41.76
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: LLUH Dept of Risk Management WC	$39.28
Rate for Payer: LLUH Dept of Risk Management WC	$38.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.56

DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]

Facility

$63.00

Service Code	CPT J2597
Hospital Charge Code	1720511
Hospital Revenue Code	636
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$47.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.76
Rate for Payer: Aetna of CA Government/Medicare	$37.80
Rate for Payer: Aetna of CA Government/Medicare	$42.85
Rate for Payer: Aetna of CA Government/Medicare	$41.76
Rate for Payer: Cash Price	$32.14
Rate for Payer: Cash Price	$28.35
Rate for Payer: Cash Price	$31.32
Rate for Payer: Health Smart Auto/Commercial	$37.80
Rate for Payer: Health Smart Auto/Commercial	$42.85
Rate for Payer: Health Smart Auto/Commercial	$41.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.76
Rate for Payer: LLUH Dept of Risk Management WC	$34.65
Rate for Payer: LLUH Dept of Risk Management WC	$38.28
Rate for Payer: LLUH Dept of Risk Management WC	$39.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.20

DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]

Facility

$0.30

Service Code	NDC 9994-0804-00
Hospital Charge Code	1715267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

DESMOPRESSIN ORAL SOLUTION COMPOUND 10 MCG/ML [4080400]

Facility

$0.30

Service Code	NDC 9994-0804-00
Hospital Charge Code	1715267
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$3.85

Service Code	NDC 0168-0309-15
Hospital Charge Code	1743237
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cigna of CA HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.89

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$3.85

Service Code	NDC 51672-1281-3
Hospital Charge Code	1743247
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cigna of CA HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.89

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$3.85

Service Code	NDC 51672-1281-1
Hospital Charge Code	1743237
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.31
Rate for Payer: Aetna of CA Government/Medicare	$2.31
Rate for Payer: Cash Price	$1.73
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.89

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$3.85

Service Code	NDC 0168-0309-15
Hospital Charge Code	1743237
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.31
Rate for Payer: Aetna of CA Government/Medicare	$2.31
Rate for Payer: Cash Price	$1.73
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.89

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$3.85

Service Code	NDC 51672-1281-3
Hospital Charge Code	1743247
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.31
Rate for Payer: Aetna of CA Government/Medicare	$2.31
Rate for Payer: Cash Price	$1.73
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.89

DESONIDE 0.05 % TOPICAL OINTMENT [9751]

Facility

$3.85

Service Code	NDC 51672-1281-1
Hospital Charge Code	1743237
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.08
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cigna of CA HMO/PPO	$3.08
Rate for Payer: Health Smart Auto/Commercial	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$2.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.89

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$3.29

Service Code	NDC 45802-495-35
Hospital Charge Code	1743316
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.63
Rate for Payer: Cash Price	$1.48
Rate for Payer: Cigna of CA HMO/PPO	$2.63
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.47

DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]

Facility

$3.29

Service Code	NDC 45802-495-35
Hospital Charge Code	1743316
Hospital Revenue Code	259
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.97
Rate for Payer: Aetna of CA Government/Medicare	$1.97
Rate for Payer: Cash Price	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.47

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$0.80

Service Code	NDC 59762-1211-3
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$0.80

Service Code	NDC 59762-1211-3
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-14
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.51
Rate for Payer: Aetna of CA Government/Medicare	$10.51
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$1.28

Service Code	NDC 0054-0400-13
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-30
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Cash Price	$7.88
Rate for Payer: Cigna of CA HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$13.95

Service Code	NDC 0008-1211-50
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$7.67
Max. Negotiated Rate	$11.16
Rate for Payer: Cash Price	$6.28
Rate for Payer: Cigna of CA HMO/PPO	$11.16
Rate for Payer: Health Smart Auto/Commercial	$8.37
Rate for Payer: LLUH Dept of Risk Management WC	$7.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.46

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-14
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Cash Price	$7.88
Rate for Payer: Cigna of CA HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$17.52

Service Code	NDC 0008-1211-30
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.51
Rate for Payer: Aetna of CA Government/Medicare	$10.51
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Smart Auto/Commercial	$10.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.51
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.14

DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]

Facility

$1.28

Service Code	NDC 0054-0400-22
Hospital Charge Code	ERX91073
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

Know your out-of-pocket cost for care.

All Charges