Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 42571-141-26
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.45
Rate for Payer: Aetna of CA Government/Medicare	$2.45
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Commercial	$3.06

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

$3.00

Service Code	NDC 61314-019-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Commercial	$2.25

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

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: Aetna of CA EPO/HMO/POS/PPO	$2.45
Rate for Payer: Aetna of CA Government/Medicare	$2.45
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.45
Rate for Payer: LLUH Dept of Risk Management WC	$2.24
Rate for Payer: Multiplan Commercial	$3.06

DORZOLAMIDE 2 % EYE DROPS [14471]

Facility

$3.00

Service Code	NDC 61314-019-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Commercial	$2.25

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$2.71

Service Code	NDC 65862-947-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.63
Rate for Payer: Aetna of CA Government/Medicare	$1.63
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.17
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$1.92

Service Code	NDC 50742-323-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$2.71

Service Code	NDC 65862-947-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.17
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.17
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$1.92

Service Code	NDC 50742-323-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$2.71

Service Code	NDC 65862-947-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.17
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.17
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$4.13

Service Code	NDC 82584-604-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$2.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.10

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$4.13

Service Code	NDC 82584-604-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.48
Rate for Payer: Aetna of CA Government/Medicare	$2.48
Rate for Payer: Cash Price	$2.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.10

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$4.13

Service Code	NDC 82584-604-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$2.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.10

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$1.92

Service Code	NDC 50742-323-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$4.13

Service Code	NDC 82584-604-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.48
Rate for Payer: Aetna of CA Government/Medicare	$2.48
Rate for Payer: Cash Price	$2.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.10

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$2.71

Service Code	NDC 65862-947-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$2.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.63
Rate for Payer: Aetna of CA Government/Medicare	$1.63
Rate for Payer: Cash Price	$1.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.17
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.49
Rate for Payer: Multiplan Commercial	$2.03

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$1.92

Service Code	NDC 50742-323-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DOXAPRAM 20 MG/ML INTRAVENOUS SOLUTION [2607]

Facility

$3.19

Service Code	NDC 0641-6018-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.55
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.55
Rate for Payer: Health Smart Auto/Commercial	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$1.75
Rate for Payer: Multiplan Commercial	$2.39

DOXAPRAM 20 MG/ML INTRAVENOUS SOLUTION [2607]

Facility

$3.19

Service Code	NDC 0641-6018-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.91
Rate for Payer: Aetna of CA Government/Medicare	$1.91
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.55
Rate for Payer: Health Smart Auto/Commercial	$1.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$1.75
Rate for Payer: Multiplan Commercial	$2.39

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.01

Service Code	NDC 68084-836-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.09

Service Code	NDC 68084-836-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82

DOXAZOSIN 1 MG TABLET [9894]

Facility

$0.51

Service Code	NDC 60505-0093-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
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	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
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	$0.28
Rate for Payer: Multiplan Commercial	$0.38

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.01

Service Code	NDC 68084-836-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.09

Service Code	NDC 68084-836-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82

Know your out-of-pocket cost for care.

All Charges