Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$1.44

Service Code	NDC 0143-3142-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.08

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$0.34

Service Code	NDC 69238-1100-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$2.01

Service Code	NDC 60687-513-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$2.45

Service Code	NDC 0904-0428-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.96
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$2.45

Service Code	NDC 0904-0428-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.47
Rate for Payer: Aetna of CA Government/Medicare	$1.47
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.96
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$0.34

Service Code	NDC 0143-9803-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$1.61

Service Code	NDC 50268-278-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$2.01

Service Code	NDC 60687-513-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$2.01

Service Code	NDC 60687-513-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$1.44

Service Code	NDC 0143-3142-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.08

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$2.01

Service Code	NDC 60687-513-65
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$0.34

Service Code	NDC 0143-9803-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$1.61

Service Code	NDC 50268-278-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$1.61

Service Code	NDC 50268-278-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

DOXYCYCLINE HYCLATE 100 MG CAPSULE [2623]

Facility

$1.61

Service Code	NDC 50268-278-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Commercial	$1.21

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]

Facility

$30.12

Service Code	HCPCS J1271
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.57
Max. Negotiated Rate	$24.10
Rate for Payer: Cash Price	$16.57
Rate for Payer: Cash Price	$17.38
Rate for Payer: Cash Price	$9.68
Rate for Payer: Cash Price	$11.00
Rate for Payer: Cash Price	$15.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.09
Rate for Payer: Health Smart Auto/Commercial	$10.57
Rate for Payer: Health Smart Auto/Commercial	$12.01
Rate for Payer: Health Smart Auto/Commercial	$17.39
Rate for Payer: Health Smart Auto/Commercial	$18.07
Rate for Payer: Health Smart Auto/Commercial	$18.96
Rate for Payer: LLUH Dept of Risk Management WC	$15.94
Rate for Payer: LLUH Dept of Risk Management WC	$17.38
Rate for Payer: LLUH Dept of Risk Management WC	$9.69
Rate for Payer: LLUH Dept of Risk Management WC	$16.57
Rate for Payer: LLUH Dept of Risk Management WC	$11.01
Rate for Payer: Multiplan Commercial	$15.01
Rate for Payer: Multiplan Commercial	$22.59
Rate for Payer: Multiplan Commercial	$23.70
Rate for Payer: Multiplan Commercial	$13.21
Rate for Payer: Multiplan Commercial	$21.74

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [2622]

Facility

$30.12

Service Code	HCPCS J1271
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.57
Max. Negotiated Rate	$24.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.57
Rate for Payer: Aetna of CA Government/Medicare	$18.07
Rate for Payer: Aetna of CA Government/Medicare	$10.57
Rate for Payer: Aetna of CA Government/Medicare	$17.39
Rate for Payer: Aetna of CA Government/Medicare	$12.01
Rate for Payer: Aetna of CA Government/Medicare	$18.96
Rate for Payer: Cash Price	$11.00
Rate for Payer: Cash Price	$15.95
Rate for Payer: Cash Price	$16.57
Rate for Payer: Cash Price	$9.68
Rate for Payer: Cash Price	$17.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.28
Rate for Payer: Health Smart Auto/Commercial	$17.39
Rate for Payer: Health Smart Auto/Commercial	$12.01
Rate for Payer: Health Smart Auto/Commercial	$18.96
Rate for Payer: Health Smart Auto/Commercial	$18.07
Rate for Payer: Health Smart Auto/Commercial	$10.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.96
Rate for Payer: LLUH Dept of Risk Management WC	$16.57
Rate for Payer: LLUH Dept of Risk Management WC	$17.38
Rate for Payer: LLUH Dept of Risk Management WC	$11.01
Rate for Payer: LLUH Dept of Risk Management WC	$9.69
Rate for Payer: LLUH Dept of Risk Management WC	$15.94
Rate for Payer: Multiplan Commercial	$23.70
Rate for Payer: Multiplan Commercial	$13.21
Rate for Payer: Multiplan Commercial	$15.01
Rate for Payer: Multiplan Commercial	$21.74
Rate for Payer: Multiplan Commercial	$22.59

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]

Facility

$31.60

Service Code	HCPCS J1271
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$17.38
Max. Negotiated Rate	$25.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.96
Rate for Payer: Aetna of CA Government/Medicare	$18.96
Rate for Payer: Cash Price	$17.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.28
Rate for Payer: Health Smart Auto/Commercial	$18.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.96
Rate for Payer: LLUH Dept of Risk Management WC	$17.38
Rate for Payer: Multiplan Commercial	$23.70

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]

Facility

$20.80

Service Code	NDC 63323-130-17
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$16.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.48
Rate for Payer: Aetna of CA Government/Medicare	$12.48
Rate for Payer: Cash Price	$11.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.64
Rate for Payer: Health Smart Auto/Commercial	$12.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.48
Rate for Payer: LLUH Dept of Risk Management WC	$11.44
Rate for Payer: Multiplan Commercial	$15.60

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]

Facility

$31.60

Service Code	HCPCS J1271
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$17.38
Max. Negotiated Rate	$25.28
Rate for Payer: Cash Price	$17.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.28
Rate for Payer: Health Smart Auto/Commercial	$18.96
Rate for Payer: LLUH Dept of Risk Management WC	$17.38
Rate for Payer: Multiplan Commercial	$23.70

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]

Facility

$20.80

Service Code	NDC 63323-130-17
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$16.64
Rate for Payer: Cash Price	$11.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.64
Rate for Payer: Health Smart Auto/Commercial	$12.48
Rate for Payer: LLUH Dept of Risk Management WC	$11.44
Rate for Payer: Multiplan Commercial	$15.60

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$0.24

Service Code	NDC 42806-312-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.29

Service Code	NDC 50268-279-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$2.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.43
Rate for Payer: Health Smart Auto/Commercial	$2.57
Rate for Payer: LLUH Dept of Risk Management WC	$2.36
Rate for Payer: Multiplan Commercial	$3.22

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$2.62

Service Code	NDC 0904-0430-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.57
Rate for Payer: Aetna of CA Government/Medicare	$1.57
Rate for Payer: Cash Price	$1.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.57
Rate for Payer: LLUH Dept of Risk Management WC	$1.44
Rate for Payer: Multiplan Commercial	$1.97

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$2.62

Service Code	NDC 0904-0430-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.57
Rate for Payer: LLUH Dept of Risk Management WC	$1.44
Rate for Payer: Multiplan Commercial	$1.97

Know your out-of-pocket cost for care.

All Charges