Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$4.35

Service Code	NDC 0904-0430-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$3.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.61
Rate for Payer: Aetna of CA Government/Medicare	$2.61
Rate for Payer: Cash Price	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.48
Rate for Payer: Health Smart Auto/Commercial	$2.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.61
Rate for Payer: LLUH Dept of Risk Management WC	$2.39
Rate for Payer: Multiplan Commercial	$3.26

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 50268-279-11
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

$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: Aetna of CA EPO/HMO/POS/PPO	$2.57
Rate for Payer: Aetna of CA Government/Medicare	$2.57
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$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 50 MG CAPSULE [2624]

Facility

$0.34

Service Code	NDC 0143-9802-50
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 50 MG CAPSULE [2624]

Facility

$0.34

Service Code	NDC 0143-9802-50
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 MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.01

Service Code	NDC 68382-707-18
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	$0.55
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

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.01

Service Code	NDC 68382-707-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.55
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: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG TABLET [110910]

Facility

$1.01

Service Code	NDC 23155-135-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.55
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: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

DOXYCYCLINE MONOHYDRATE 100 MG TABLET [110910]

Facility

$1.01

Service Code	NDC 23155-135-25
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	$0.55
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

DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9901]

Facility

$0.65

Service Code	NDC 50268-280-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9901]

Facility

$0.65

Service Code	NDC 50268-280-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE [186780]

Facility

$2.50

Service Code	NDC 55494-100-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.00
Rate for Payer: Cash Price	$1.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.00
Rate for Payer: Health Smart Auto/Commercial	$1.50
Rate for Payer: LLUH Dept of Risk Management WC	$1.38
Rate for Payer: Multiplan Commercial	$1.88

DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE [186780]

Facility

$2.50

Service Code	NDC 55494-100-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.50
Rate for Payer: Aetna of CA Government/Medicare	$1.50
Rate for Payer: Cash Price	$1.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.00
Rate for Payer: Health Smart Auto/Commercial	$1.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.50
Rate for Payer: LLUH Dept of Risk Management WC	$1.38
Rate for Payer: Multiplan Commercial	$1.88

DOXYLAMINE 6.25 MG-PE 5 MG-DM 10 MG-ACETAMINOPHEN 325MG/15ML ORAL LIQD [77082]

Facility

$0.03

Service Code	NDC 37000-815-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

DOXYLAMINE 6.25 MG-PE 5 MG-DM 10 MG-ACETAMINOPHEN 325MG/15ML ORAL LIQD [77082]

Facility

$0.03

Service Code	NDC 37000-815-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

DOXYLAMINE SUCCINATE 25 MG TABLET [14847]

Facility

$0.23

Service Code	NDC 24385-441-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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	$0.17

DOXYLAMINE SUCCINATE 25 MG TABLET [14847]

Facility

$0.23

Service Code	NDC 24385-441-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

DOXYLAMINE SUCCINATE 25 MG TABLET [14847]

Facility

$0.34

Service Code	NDC 4116700607
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
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

Know your out-of-pocket cost for care.

All Charges