Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [2516]

Facility

$0.20

Service Code	NDC 62559-490-01
Hospital Charge Code	1730124
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
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	$0.09
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 Beech St/Commercial/PHCS	$0.15

DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]

Facility

$80.39

Service Code	CPT 90700
Hospital Charge Code	1721221
Hospital Revenue Code	636
Min. Negotiated Rate	$44.21
Max. Negotiated Rate	$64.31
Rate for Payer: Cash Price	$36.18
Rate for Payer: Cigna of CA HMO/PPO	$64.31
Rate for Payer: Health Smart Auto/Commercial	$48.23
Rate for Payer: LLUH Dept of Risk Management WC	$44.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.29

DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP [119613]

Facility

$80.39

Service Code	CPT 90700
Hospital Charge Code	1721221
Hospital Revenue Code	636
Min. Negotiated Rate	$44.21
Max. Negotiated Rate	$60.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.23
Rate for Payer: Aetna of CA Government/Medicare	$48.23
Rate for Payer: Cash Price	$36.18
Rate for Payer: Health Smart Auto/Commercial	$48.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.23
Rate for Payer: LLUH Dept of Risk Management WC	$44.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.29

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

$61.85

Service Code	CPT 90700
Hospital Charge Code	1712559
Hospital Revenue Code	636
Min. Negotiated Rate	$34.02
Max. Negotiated Rate	$46.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.11
Rate for Payer: Aetna of CA Government/Medicare	$37.11
Rate for Payer: Cash Price	$27.83
Rate for Payer: Health Smart Auto/Commercial	$37.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.11
Rate for Payer: LLUH Dept of Risk Management WC	$34.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$46.39

DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [19451]

Facility

$61.85

Service Code	CPT 90700
Hospital Charge Code	1712559
Hospital Revenue Code	636
Min. Negotiated Rate	$34.02
Max. Negotiated Rate	$49.48
Rate for Payer: Cash Price	$27.83
Rate for Payer: Cigna of CA HMO/PPO	$49.48
Rate for Payer: Health Smart Auto/Commercial	$37.11
Rate for Payer: LLUH Dept of Risk Management WC	$34.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$46.39

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

Facility

$120.38

Service Code	CPT 90715
Hospital Charge Code	1726023
Hospital Revenue Code	636
Min. Negotiated Rate	$66.21
Max. Negotiated Rate	$90.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.23
Rate for Payer: Aetna of CA Government/Medicare	$72.23
Rate for Payer: Cash Price	$54.17
Rate for Payer: Health Smart Auto/Commercial	$72.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.23
Rate for Payer: LLUH Dept of Risk Management WC	$66.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.28

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

Facility

$120.38

Service Code	CPT 90715
Hospital Charge Code	1726023
Hospital Revenue Code	636
Min. Negotiated Rate	$66.21
Max. Negotiated Rate	$96.30
Rate for Payer: Cash Price	$54.17
Rate for Payer: Cigna of CA HMO/PPO	$96.30
Rate for Payer: Health Smart Auto/Commercial	$72.23
Rate for Payer: LLUH Dept of Risk Management WC	$66.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.28

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

Facility

$105.19

Service Code	CPT 90715
Hospital Charge Code	ERX186294
Hospital Revenue Code	636
Min. Negotiated Rate	$57.85
Max. Negotiated Rate	$84.15
Rate for Payer: Cash Price	$47.34
Rate for Payer: Cigna of CA HMO/PPO	$84.15
Rate for Payer: Health Smart Auto/Commercial	$63.11
Rate for Payer: LLUH Dept of Risk Management WC	$57.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$78.89

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

Facility

$105.19

Service Code	CPT 90715
Hospital Charge Code	ERX186294
Hospital Revenue Code	636
Min. Negotiated Rate	$57.85
Max. Negotiated Rate	$78.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$63.11
Rate for Payer: Aetna of CA Government/Medicare	$63.11
Rate for Payer: Cash Price	$47.34
Rate for Payer: Health Smart Auto/Commercial	$63.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$63.11
Rate for Payer: LLUH Dept of Risk Management WC	$57.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$78.89

DIPYRIDAMOLE 25 MG TABLET [2528]

Facility

$0.21

Service Code	NDC 64980-133-10
Hospital Charge Code	1710561
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
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	$0.09
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 Beech St/Commercial/PHCS	$0.16

DIPYRIDAMOLE 25 MG TABLET [2528]

Facility

$0.21

Service Code	NDC 64980-133-10
Hospital Charge Code	1710561
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.16

DIPYRIDAMOLE 75 MG TABLET [2530]

Facility

$3.06

Service Code	NDC 64980-135-01
Hospital Charge Code	1710594
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.45
Rate for Payer: Cash Price	$1.38
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.30

DIPYRIDAMOLE 75 MG TABLET [2530]

Facility

$3.06

Service Code	NDC 64980-135-01
Hospital Charge Code	1710594
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.30
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	$1.38
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 Beech St/Commercial/PHCS	$2.30

DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]

Facility

$0.07

Service Code	NDC 9994-0802-65
Hospital Charge Code	ERX4080265
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.05

DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]

Facility

$0.07

Service Code	NDC 9994-0802-65
Hospital Charge Code	ERX4080265
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
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	$0.03
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 Beech St/Commercial/PHCS	$0.05

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$2.39

Service Code	NDC 0093-3127-01
Hospital Charge Code	1710215
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.91
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.79

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$2.39

Service Code	NDC 0093-3127-01
Hospital Charge Code	1710215
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.79
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	$1.08
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 Beech St/Commercial/PHCS	$1.79

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$5.61

Service Code	NDC 0025-2752-31
Hospital Charge Code	1710215
Hospital Revenue Code	259
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.49
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cigna of CA HMO/PPO	$4.49
Rate for Payer: Health Smart Auto/Commercial	$3.37
Rate for Payer: LLUH Dept of Risk Management WC	$3.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.21

DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]

Facility

$5.61

Service Code	NDC 0025-2752-31
Hospital Charge Code	1710215
Hospital Revenue Code	259
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.37
Rate for Payer: Aetna of CA Government/Medicare	$3.37
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Smart Auto/Commercial	$3.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.37
Rate for Payer: LLUH Dept of Risk Management WC	$3.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.21

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]

Facility

$6.63

Service Code	NDC 0025-2762-31
Hospital Charge Code	1710229
Hospital Revenue Code	259
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$5.30
Rate for Payer: Cash Price	$2.98
Rate for Payer: Cigna of CA HMO/PPO	$5.30
Rate for Payer: Health Smart Auto/Commercial	$3.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.97

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]

Facility

$6.63

Service Code	NDC 0025-2762-31
Hospital Charge Code	1710229
Hospital Revenue Code	259
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$4.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.98
Rate for Payer: Aetna of CA Government/Medicare	$3.98
Rate for Payer: Cash Price	$2.98
Rate for Payer: Health Smart Auto/Commercial	$3.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.97

DISULFIRAM 250 MG TABLET [2540]

Facility

$2.39

Service Code	NDC 64980-171-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.91
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.79

DISULFIRAM 250 MG TABLET [2540]

Facility

$3.92

Service Code	NDC 0093-5035-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$3.14
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of CA HMO/PPO	$3.14
Rate for Payer: Health Smart Auto/Commercial	$2.35
Rate for Payer: LLUH Dept of Risk Management WC	$2.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.94

DISULFIRAM 250 MG TABLET [2540]

Facility

$3.92

Service Code	NDC 0093-5035-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$2.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.35
Rate for Payer: Aetna of CA Government/Medicare	$2.35
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Smart Auto/Commercial	$2.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.35
Rate for Payer: LLUH Dept of Risk Management WC	$2.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.94

DISULFIRAM 250 MG TABLET [2540]

Facility

$2.39

Service Code	NDC 64980-171-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.79
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	$1.08
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 Beech St/Commercial/PHCS	$1.79

Know your out-of-pocket cost for care.

All Charges