Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

$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

$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

DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]

Facility

$38.40

Service Code	CPT J3490
Hospital Charge Code	NDG221697
Hospital Revenue Code	636
Min. Negotiated Rate	$21.12
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.04
Rate for Payer: Aetna of CA Government/Medicare	$23.04
Rate for Payer: Cash Price	$17.28
Rate for Payer: Health Smart Auto/Commercial	$23.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.04
Rate for Payer: LLUH Dept of Risk Management WC	$21.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.80

DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]

Facility

$38.40

Service Code	CPT J3490
Hospital Charge Code	NDG221697
Hospital Revenue Code	636
Min. Negotiated Rate	$21.12
Max. Negotiated Rate	$30.72
Rate for Payer: Cash Price	$17.28
Rate for Payer: Cigna of CA HMO/PPO	$30.72
Rate for Payer: Health Smart Auto/Commercial	$23.04
Rate for Payer: LLUH Dept of Risk Management WC	$21.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.80

DEXAMETHASONE 0.1% EYE DROPS. [4082335]

Facility

$4.03

Service Code	NDC 61314-294-05
Hospital Charge Code	1740106
Hospital Revenue Code	259
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.42
Rate for Payer: Aetna of CA Government/Medicare	$2.42
Rate for Payer: Cash Price	$1.81
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.02

DEXAMETHASONE 0.1% EYE DROPS. [4082335]

Facility

$19.00

Service Code	NDC 0998-0615-05
Hospital Charge Code	1740106
Hospital Revenue Code	259
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$14.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.40
Rate for Payer: Aetna of CA Government/Medicare	$11.40
Rate for Payer: Cash Price	$8.55
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.25

DEXAMETHASONE 0.1% EYE DROPS. [4082335]

Facility

$12.94

Service Code	NDC 24208-720-02
Hospital Charge Code	1740106
Hospital Revenue Code	259
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$9.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.76
Rate for Payer: Aetna of CA Government/Medicare	$7.76
Rate for Payer: Cash Price	$5.82
Rate for Payer: Health Smart Auto/Commercial	$7.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.76
Rate for Payer: LLUH Dept of Risk Management WC	$7.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.70

DEXAMETHASONE 0.1% EYE DROPS. [4082335]

Facility

$12.94

Service Code	NDC 24208-720-02
Hospital Charge Code	1740106
Hospital Revenue Code	259
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$10.35
Rate for Payer: Cash Price	$5.82
Rate for Payer: Cigna of CA HMO/PPO	$10.35
Rate for Payer: Health Smart Auto/Commercial	$7.76
Rate for Payer: LLUH Dept of Risk Management WC	$7.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.70

DEXAMETHASONE 0.1% EYE DROPS. [4082335]

Facility

$19.00

Service Code	NDC 0998-0615-05
Hospital Charge Code	1740106
Hospital Revenue Code	259
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$15.20
Rate for Payer: Cash Price	$8.55
Rate for Payer: Cigna of CA HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.25

DEXAMETHASONE 0.1% EYE DROPS. [4082335]

Facility

$4.03

Service Code	NDC 61314-294-05
Hospital Charge Code	1740106
Hospital Revenue Code	259
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.22
Rate for Payer: Cash Price	$1.81
Rate for Payer: Cigna of CA HMO/PPO	$3.22
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.02

DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION [2320]

Facility

$0.04

Service Code	CPT J8540
Hospital Charge Code	1715664
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION [2320]

Facility

$0.04

Service Code	CPT J8540
Hospital Charge Code	1715664
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

DEXAMETHASONE 0.5 MG TABLET [2322]

Facility

$0.21

Service Code	CPT J8540
Hospital Charge Code	1710096
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

DEXAMETHASONE 0.5 MG TABLET [2322]

Facility

$0.21

Service Code	CPT J8540
Hospital Charge Code	1710096
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

DEXAMETHASONE 10 MG/ML MED NEB SOLUTION [192189]

Facility

$1.72

Service Code	NDC 0641-0367-21
Hospital Charge Code	1730171
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

DEXAMETHASONE 10 MG/ML MED NEB SOLUTION [192189]

Facility

$1.72

Service Code	NDC 0641-0367-21
Hospital Charge Code	1730171
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.77
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

DEXAMETHASONE 10 MG/ML SUBCONJUNCTIVAL INJECTION [4081910]

Facility

$1.72

Service Code	CPT J1100
Hospital Charge Code	1730171
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.77
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

DEXAMETHASONE 10 MG/ML SUBCONJUNCTIVAL INJECTION [4081910]

Facility

$1.86

Service Code	CPT J1100
Hospital Charge Code	1720453
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.49
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna of CA HMO/PPO	$1.49
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.40

DEXAMETHASONE 10 MG/ML SUBCONJUNCTIVAL INJECTION [4081910]

Facility

$1.86

Service Code	CPT J1100
Hospital Charge Code	1720453
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.12
Rate for Payer: Aetna of CA Government/Medicare	$1.12
Rate for Payer: Cash Price	$0.84
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.40

DEXAMETHASONE 10 MG/ML SUBCONJUNCTIVAL INJECTION [4081910]

Facility

$1.72

Service Code	CPT J1100
Hospital Charge Code	1730171
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cigna of CA HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.29

DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE) [110922]

Facility

$0.95

Service Code	NDC 0054-3176-44
Hospital Charge Code	1715988
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.43
Rate for Payer: Cigna of CA HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE) [110922]

Facility

$0.95

Service Code	NDC 0054-3176-44
Hospital Charge Code	1715988
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.57
Rate for Payer: Aetna of CA Government/Medicare	$0.57
Rate for Payer: Cash Price	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

DEXAMETHASONE 1 MG-MOXIFLOXACIN 5 MG/ML (PF)-NACL,ISO INTRAOCULAR SOLN [221704]

Facility

$34.80

Service Code	CPT J3490
Hospital Charge Code	NDG221704
Hospital Revenue Code	636
Min. Negotiated Rate	$19.14
Max. Negotiated Rate	$27.84
Rate for Payer: Cash Price	$15.66
Rate for Payer: Cigna of CA HMO/PPO	$27.84
Rate for Payer: Health Smart Auto/Commercial	$20.88
Rate for Payer: LLUH Dept of Risk Management WC	$19.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.10

DEXAMETHASONE 1 MG-MOXIFLOXACIN 5 MG/ML (PF)-NACL,ISO INTRAOCULAR SOLN [221704]

Facility

$34.80

Service Code	CPT J3490
Hospital Charge Code	NDG221704
Hospital Revenue Code	636
Min. Negotiated Rate	$19.14
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.88
Rate for Payer: Aetna of CA Government/Medicare	$20.88
Rate for Payer: Cash Price	$15.66
Rate for Payer: Health Smart Auto/Commercial	$20.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.88
Rate for Payer: LLUH Dept of Risk Management WC	$19.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.10

Know your out-of-pocket cost for care.

All Charges