Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]

Facility

$112.68

Service Code	HCPCS 90715
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$61.97
Max. Negotiated Rate	$90.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.61
Rate for Payer: Aetna of CA Government/Medicare	$67.61
Rate for Payer: Cash Price	$61.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.14
Rate for Payer: Health Smart Auto/Commercial	$67.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.61
Rate for Payer: LLUH Dept of Risk Management WC	$61.97
Rate for Payer: Multiplan Commercial	$84.51

DIPHTH,PERTUS(AC)TETANUS VAC (PF) 2 LF-(5-3-5MCG)-5LF/0.5ML IM WRAP [408119727]

Facility

$112.68

Service Code	HCPCS 90715
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$61.97
Max. Negotiated Rate	$90.14
Rate for Payer: Cash Price	$61.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.14
Rate for Payer: Health Smart Auto/Commercial	$67.61
Rate for Payer: LLUH Dept of Risk Management WC	$61.97
Rate for Payer: Multiplan Commercial	$84.51

DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]

Facility

$111.59

Service Code	HCPCS 90715
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$61.37
Max. Negotiated Rate	$89.27
Rate for Payer: Cash Price	$61.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.27
Rate for Payer: Health Smart Auto/Commercial	$66.95
Rate for Payer: LLUH Dept of Risk Management WC	$61.37
Rate for Payer: Multiplan Commercial	$83.69

DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]

Facility

$111.59

Service Code	HCPCS 90715
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$61.37
Max. Negotiated Rate	$89.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.95
Rate for Payer: Aetna of CA Government/Medicare	$66.95
Rate for Payer: Cash Price	$61.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.27
Rate for Payer: Health Smart Auto/Commercial	$66.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.95
Rate for Payer: LLUH Dept of Risk Management WC	$61.37
Rate for Payer: Multiplan Commercial	$83.69

DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]

Facility

$139.57

Service Code	HCPCS 90698
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$76.76
Max. Negotiated Rate	$111.66
Rate for Payer: Cash Price	$76.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.66
Rate for Payer: Health Smart Auto/Commercial	$83.74
Rate for Payer: LLUH Dept of Risk Management WC	$76.76
Rate for Payer: Multiplan Commercial	$104.68

DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]

Facility

$139.57

Service Code	HCPCS 90698
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$76.76
Max. Negotiated Rate	$111.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$83.74
Rate for Payer: Aetna of CA Government/Medicare	$83.74
Rate for Payer: Cash Price	$76.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.66
Rate for Payer: Health Smart Auto/Commercial	$83.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$83.74
Rate for Payer: LLUH Dept of Risk Management WC	$76.76
Rate for Payer: Multiplan Commercial	$104.68

DIPYRIDAMOLE 25 MG TABLET [2528]

Facility

$0.21

Service Code	NDC 64980-133-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.16

DIPYRIDAMOLE 25 MG TABLET [2528]

Facility

$0.21

Service Code	NDC 64980-133-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
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	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

DIPYRIDAMOLE 75 MG TABLET [2530]

Facility

$3.06

Service Code	NDC 64980-135-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.45
Rate for Payer: Cash Price	$1.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.45
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Commercial	$2.29

DIPYRIDAMOLE 75 MG TABLET [2530]

Facility

$3.06

Service Code	NDC 64980-135-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.84
Rate for Payer: Aetna of CA Government/Medicare	$1.84
Rate for Payer: Cash Price	$1.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.45
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.84
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Commercial	$2.29

DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]

Facility

$0.07

Service Code	NDC 9994-0802-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]

Facility

$0.07

Service Code	NDC 9994-0802-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$2.39

Service Code	NDC 0093-3127-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.91
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.91
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Commercial	$1.79

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$5.72

Service Code	NDC 0025-2752-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$3.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Commercial	$4.29

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$2.39

Service Code	NDC 0093-3127-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.43
Rate for Payer: Aetna of CA Government/Medicare	$1.43
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.91
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Commercial	$1.79

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$5.72

Service Code	NDC 0025-2752-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.43
Rate for Payer: Aetna of CA Government/Medicare	$3.43
Rate for Payer: Cash Price	$3.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Commercial	$4.29

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]

Facility

$6.76

Service Code	NDC 0025-2762-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$5.41
Rate for Payer: Cash Price	$3.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.41
Rate for Payer: Health Smart Auto/Commercial	$4.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.72
Rate for Payer: Multiplan Commercial	$5.07

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]

Facility

$6.76

Service Code	NDC 0025-2762-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$5.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.06
Rate for Payer: Aetna of CA Government/Medicare	$4.06
Rate for Payer: Cash Price	$3.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.41
Rate for Payer: Health Smart Auto/Commercial	$4.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.72
Rate for Payer: Multiplan Commercial	$5.07

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$1.00

Service Code	NDC 68084-313-11
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

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$0.68

Service Code	NDC 68382-106-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$2.35

Service Code	NDC 0074-6114-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.41
Rate for Payer: Aetna of CA Government/Medicare	$1.41
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.88
Rate for Payer: Health Smart Auto/Commercial	$1.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.76

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$0.68

Service Code	NDC 68382-106-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$2.35

Service Code	NDC 0074-6114-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.88
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.88
Rate for Payer: Health Smart Auto/Commercial	$1.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.76

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$0.60

Service Code	NDC 27241-115-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility

$1.00

Service Code	NDC 68084-313-01
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

Know your out-of-pocket cost for care.

All Charges