Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DICYCLOMINE 20 MG TABLET [2420]

Facility

$0.19

Service Code	NDC 0591-0795-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION [9853]

Facility

$165.28

Service Code	HCPCS J1160
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$132.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$99.17
Rate for Payer: Aetna of CA Government/Medicare	$99.17
Rate for Payer: Cash Price	$90.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$132.22
Rate for Payer: Health Smart Auto/Commercial	$99.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$99.17
Rate for Payer: LLUH Dept of Risk Management WC	$90.90
Rate for Payer: Multiplan Commercial	$123.96

DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION [9853]

Facility

$165.28

Service Code	HCPCS J1160
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$132.22
Rate for Payer: Cash Price	$90.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$132.22
Rate for Payer: Health Smart Auto/Commercial	$99.17
Rate for Payer: LLUH Dept of Risk Management WC	$90.90
Rate for Payer: Multiplan Commercial	$123.96

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.46

Service Code	NDC 60687-858-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.17
Rate for Payer: Cash Price	$0.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.17
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$1.09

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$0.36

Service Code	NDC 0143-1240-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.74

Service Code	NDC 68084-366-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.39
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.30

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.74

Service Code	NDC 68084-366-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.30

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.62

Service Code	NDC 0904-5921-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.30
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.30
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.22

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$0.36

Service Code	NDC 0143-1240-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.46

Service Code	NDC 60687-858-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.17
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$1.09

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$0.22

Service Code	NDC 10135-747-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$0.22

Service Code	NDC 10135-747-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
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	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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 Commercial	$0.17

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.46

Service Code	NDC 60687-858-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.17
Rate for Payer: Cash Price	$0.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.17
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$1.09

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.46

Service Code	NDC 60687-858-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.17
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$1.09

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.62

Service Code	NDC 0904-5921-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.30
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.22

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.74

Service Code	NDC 68084-366-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.04
Rate for Payer: Aetna of CA Government/Medicare	$1.04
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.30

DIGOXIN 125 MCG (0.125 MG) TABLET [2444]

Facility

$1.74

Service Code	NDC 68084-366-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.39
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.30

DIGOXIN 250 MCG (0.25 MG) TABLET [2445]

Facility

$1.62

Service Code	NDC 0904-5922-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.30
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.30
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.22

DIGOXIN 250 MCG (0.25 MG) TABLET [2445]

Facility

$1.62

Service Code	NDC 0904-5922-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.30
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.22

DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [110919]

Facility

$3.59

Service Code	HCPCS J1160
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.58
Rate for Payer: Aetna of CA Government/Medicare	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$1.98
Rate for Payer: Aetna of CA Government/Medicare	$49.58
Rate for Payer: Cash Price	$45.45
Rate for Payer: Cash Price	$1.81
Rate for Payer: Cash Price	$1.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.11
Rate for Payer: Health Smart Auto/Commercial	$1.98
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Health Smart Auto/Commercial	$49.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$45.45
Rate for Payer: Multiplan Commercial	$2.48
Rate for Payer: Multiplan Commercial	$2.69
Rate for Payer: Multiplan Commercial	$61.98

DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [110919]

Facility

$3.59

Service Code	HCPCS J1160
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.87
Rate for Payer: Cash Price	$1.97
Rate for Payer: Cash Price	$1.81
Rate for Payer: Cash Price	$45.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.87
Rate for Payer: Health Smart Auto/Commercial	$49.58
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Health Smart Auto/Commercial	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$1.81
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$45.45
Rate for Payer: Multiplan Commercial	$2.69
Rate for Payer: Multiplan Commercial	$2.48
Rate for Payer: Multiplan Commercial	$61.98

DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]

Facility

$2.80

Service Code	NDC 0054-0057-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.68
Rate for Payer: Aetna of CA Government/Medicare	$1.68
Rate for Payer: Cash Price	$1.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.24
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Commercial	$2.10

DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION [43556]

Facility

$2.80

Service Code	NDC 0054-0057-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.24
Rate for Payer: Cash Price	$1.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.24
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Commercial	$2.10

DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION [9859]

Facility

$101.05

Service Code	HCPCS J1110
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$55.58
Max. Negotiated Rate	$80.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.63
Rate for Payer: Aetna of CA Government/Medicare	$60.63
Rate for Payer: Cash Price	$55.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.84
Rate for Payer: Health Smart Auto/Commercial	$60.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.63
Rate for Payer: LLUH Dept of Risk Management WC	$55.58
Rate for Payer: Multiplan Commercial	$75.79

DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION [9859]

Facility

$101.05

Service Code	HCPCS J1110
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$55.58
Max. Negotiated Rate	$80.84
Rate for Payer: Cash Price	$55.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.84
Rate for Payer: Health Smart Auto/Commercial	$60.63
Rate for Payer: LLUH Dept of Risk Management WC	$55.58
Rate for Payer: Multiplan Commercial	$75.79

Know your out-of-pocket cost for care.

All Charges