Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$6.32

Service Code	NDC 0904-6683-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$5.06
Rate for Payer: Cash Price	$3.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.06
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: LLUH Dept of Risk Management WC	$3.48
Rate for Payer: Multiplan Commercial	$4.74

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$0.40

Service Code	NDC 72205-041-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$13.43

Service Code	NDC 0069-5820-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.39
Max. Negotiated Rate	$10.74
Rate for Payer: Cash Price	$7.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.74
Rate for Payer: Health Smart Auto/Commercial	$8.06
Rate for Payer: LLUH Dept of Risk Management WC	$7.39
Rate for Payer: Multiplan Commercial	$10.07

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$0.40

Service Code	NDC 72205-041-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$13.43

Service Code	NDC 0069-5820-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.39
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.06
Rate for Payer: Aetna of CA Government/Medicare	$8.06
Rate for Payer: Cash Price	$7.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.74
Rate for Payer: Health Smart Auto/Commercial	$8.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.06
Rate for Payer: LLUH Dept of Risk Management WC	$7.39
Rate for Payer: Multiplan Commercial	$10.07

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$6.32

Service Code	NDC 0904-6683-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$5.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.79
Rate for Payer: Aetna of CA Government/Medicare	$3.79
Rate for Payer: Cash Price	$3.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.06
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.79
Rate for Payer: LLUH Dept of Risk Management WC	$3.48
Rate for Payer: Multiplan Commercial	$4.74

DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]

Facility

$146.11

Service Code	NDC 49702-242-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$80.36
Max. Negotiated Rate	$116.89
Rate for Payer: Cash Price	$80.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$116.89
Rate for Payer: Health Smart Auto/Commercial	$87.67
Rate for Payer: LLUH Dept of Risk Management WC	$80.36
Rate for Payer: Multiplan Commercial	$109.58

DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]

Facility

$146.11

Service Code	NDC 49702-242-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$80.36
Max. Negotiated Rate	$116.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$87.67
Rate for Payer: Aetna of CA Government/Medicare	$87.67
Rate for Payer: Cash Price	$80.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$116.89
Rate for Payer: Health Smart Auto/Commercial	$87.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$87.67
Rate for Payer: LLUH Dept of Risk Management WC	$80.36
Rate for Payer: Multiplan Commercial	$109.58

DOLUTEGRAVIR 50 MG TABLET [201546]

Facility

$93.01

Service Code	NDC 49702-228-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$74.41
Rate for Payer: Cash Price	$51.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$74.41
Rate for Payer: Health Smart Auto/Commercial	$55.81
Rate for Payer: LLUH Dept of Risk Management WC	$51.16
Rate for Payer: Multiplan Commercial	$69.76

DOLUTEGRAVIR 50 MG TABLET [201546]

Facility

$93.01

Service Code	NDC 49702-228-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$74.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.81
Rate for Payer: Aetna of CA Government/Medicare	$55.81
Rate for Payer: Cash Price	$51.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$74.41
Rate for Payer: Health Smart Auto/Commercial	$55.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.81
Rate for Payer: LLUH Dept of Risk Management WC	$51.16
Rate for Payer: Multiplan Commercial	$69.76

DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]

Facility

$42.26

Service Code	HCPCS J0175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$23.24
Max. Negotiated Rate	$33.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.36
Rate for Payer: Aetna of CA Government/Medicare	$25.36
Rate for Payer: Cash Price	$23.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.81
Rate for Payer: Health Smart Auto/Commercial	$25.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.36
Rate for Payer: LLUH Dept of Risk Management WC	$23.24
Rate for Payer: Multiplan Commercial	$31.70

DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION [242172]

Facility

$42.26

Service Code	HCPCS J0175
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$23.24
Max. Negotiated Rate	$33.81
Rate for Payer: Cash Price	$23.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.81
Rate for Payer: Health Smart Auto/Commercial	$25.36
Rate for Payer: LLUH Dept of Risk Management WC	$23.24
Rate for Payer: Multiplan Commercial	$31.70

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 0904-6478-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.20

Service Code	NDC 43547-276-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.20

Service Code	NDC 43547-276-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 0904-6478-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.18

Service Code	NDC 13668-102-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.16

Service Code	NDC 0904-6477-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.52

Service Code	NDC 59762-0245-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.20

Service Code	NDC 43547-275-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.18

Service Code	NDC 13668-102-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
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	$0.14
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

Know your out-of-pocket cost for care.

All Charges