Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$3.48

Service Code	NDC 0378-6090-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.09
Rate for Payer: Aetna of CA Government/Medicare	$2.09
Rate for Payer: Cash Price	$1.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Commercial	$2.61

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$4.67

Service Code	NDC 51079-925-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.80
Rate for Payer: Aetna of CA Government/Medicare	$2.80
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.80
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.50

DILTIAZEM ER 90 MG CAPSULE,EXTENDED RELEASE 12 HR [14101]

Facility

$4.67

Service Code	NDC 51079-925-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.80
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.50

DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]

Facility

$0.45

Service Code	NDC 9994-0802-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

DILTIAZEM ORAL SUSPENSION COMPOUND 12 MG/ML [4080264]

Facility

$0.45

Service Code	NDC 9994-0802-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

DILTIAZEM TOPICAL GEL 2 % (COMPOUNDED) [4081048]

Facility

$0.30

Service Code	NDC 9994-0810-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.23

DILTIAZEM TOPICAL GEL 2 % (COMPOUNDED) [4081048]

Facility

$0.30

Service Code	NDC 9994-0810-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
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	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
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 Commercial	$0.23

DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]

Facility

$0.35

Service Code	NDC 0173-0857-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]

Facility

$0.35

Service Code	NDC 0173-0857-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]

Facility

$0.35

Service Code	NDC 0173-0857-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DILUENT FOR EPOPROSTENOL (GLYCINE) PH 11.7 - 12.3 INTRAVENOUS SOLUTION [228006]

Facility

$0.35

Service Code	NDC 0173-0857-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]

Facility

$0.30

Service Code	NDC 66302-150-50
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
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	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
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 Commercial	$0.23

DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]

Facility

$0.43

Service Code	NDC 0781-6021-94
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]

Facility

$0.43

Service Code	NDC 0781-6021-94
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION [216816]

Facility

$0.30

Service Code	NDC 66302-150-50
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.23

DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]

Facility

$15.77

Service Code	HCPCS J1240
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.62
Rate for Payer: Health Smart Auto/Commercial	$9.46
Rate for Payer: LLUH Dept of Risk Management WC	$8.67
Rate for Payer: Multiplan Commercial	$11.83

DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION [2483]

Facility

$15.77

Service Code	HCPCS J1240
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$12.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.46
Rate for Payer: Aetna of CA Government/Medicare	$9.46
Rate for Payer: Cash Price	$8.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.62
Rate for Payer: Health Smart Auto/Commercial	$9.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.46
Rate for Payer: LLUH Dept of Risk Management WC	$8.67
Rate for Payer: Multiplan Commercial	$11.83

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]

Facility

$660.22

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$363.12
Max. Negotiated Rate	$528.18
Rate for Payer: Cash Price	$363.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.18
Rate for Payer: Health Smart Auto/Commercial	$396.13
Rate for Payer: LLUH Dept of Risk Management WC	$363.12
Rate for Payer: Multiplan Commercial	$495.17

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]

Facility

$660.22

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$363.12
Max. Negotiated Rate	$528.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$396.13
Rate for Payer: Aetna of CA Government/Medicare	$396.13
Rate for Payer: Cash Price	$363.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$528.18
Rate for Payer: Health Smart Auto/Commercial	$396.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$396.13
Rate for Payer: LLUH Dept of Risk Management WC	$363.12
Rate for Payer: Multiplan Commercial	$495.17

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$1.00

Service Code	NDC 0121-0489-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$0.01

Service Code	NDC 9999-2511-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$1.00

Service Code	NDC 0121-0489-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$1.00

Service Code	NDC 0121-0489-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$1.00

Service Code	NDC 0121-0489-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]

Facility

$0.01

Service Code	NDC 9999-2511-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.01

Know your out-of-pocket cost for care.

All Charges