Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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 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

$0.52

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: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION [2595]

Facility

$0.70

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72
Rate for Payer: Multiplan Commercial	$0.53

DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION [2595]

Facility

$0.96

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.53
Rate for Payer: Multiplan Commercial	$0.72

DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]

Facility

$0.07

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]

Facility

$0.07

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]

Facility

$0.07

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]

Facility

$0.07

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]

Facility

$0.10

Service Code	HCPCS J1265
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$64.21

Service Code	NDC 50242-100-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$35.32
Max. Negotiated Rate	$51.37
Rate for Payer: Cash Price	$35.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.37
Rate for Payer: Health Smart Auto/Commercial	$38.53
Rate for Payer: LLUH Dept of Risk Management WC	$35.32
Rate for Payer: Multiplan Commercial	$48.16

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$64.21

Service Code	NDC 50242-100-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$35.32
Max. Negotiated Rate	$51.37
Rate for Payer: Cash Price	$35.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.37
Rate for Payer: Health Smart Auto/Commercial	$38.53
Rate for Payer: LLUH Dept of Risk Management WC	$35.32
Rate for Payer: Multiplan Commercial	$48.16

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$64.21

Service Code	NDC 50242-100-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$35.32
Max. Negotiated Rate	$51.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.53
Rate for Payer: Aetna of CA Government/Medicare	$38.53
Rate for Payer: Cash Price	$35.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.37
Rate for Payer: Health Smart Auto/Commercial	$38.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.53
Rate for Payer: LLUH Dept of Risk Management WC	$35.32
Rate for Payer: Multiplan Commercial	$48.16

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$64.21

Service Code	NDC 50242-100-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$35.32
Max. Negotiated Rate	$51.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.53
Rate for Payer: Aetna of CA Government/Medicare	$38.53
Rate for Payer: Cash Price	$35.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.37
Rate for Payer: Health Smart Auto/Commercial	$38.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.53
Rate for Payer: LLUH Dept of Risk Management WC	$35.32
Rate for Payer: Multiplan Commercial	$48.16

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$2.40

Service Code	NDC 61314-030-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$6.00

Service Code	NDC 42571-147-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$2.40

Service Code	NDC 61314-030-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$6.00

Service Code	NDC 24208-486-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$6.00

Service Code	NDC 24208-486-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$6.00

Service Code	NDC 42571-147-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

$1.80

Service Code	NDC 72266-197-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.35

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

$4.08

Service Code	NDC 24208-485-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.26
Rate for Payer: Cash Price	$2.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.26
Rate for Payer: Health Smart Auto/Commercial	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Commercial	$3.06

Know your out-of-pocket cost for care.

All Charges