Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DIVALPROEX 500 MG TABLET,DELAYED RELEASE [2553]

Facility

$0.43

Service Code	NDC 68084-782-11
Hospital Charge Code	1711348
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

DIVALPROEX 500 MG TABLET,DELAYED RELEASE [2553]

Facility

$0.78

Service Code	NDC 29300-140-01
Hospital Charge Code	1711348
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

DIVALPROEX 500 MG TABLET,DELAYED RELEASE [2553]

Facility

$0.43

Service Code	NDC 68084-782-11
Hospital Charge Code	1711348
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]

Facility

$0.47

Service Code	NDC 50268-259-11
Hospital Charge Code	1711850
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]

Facility

$0.15

Service Code	NDC 65862-594-01
Hospital Charge Code	1711850
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]

Facility

$0.47

Service Code	NDC 50268-259-11
Hospital Charge Code	1711850
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR [34418]

Facility

$0.15

Service Code	NDC 65862-594-01
Hospital Charge Code	1711850
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$2.63

Service Code	NDC 68084-415-11
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.58
Rate for Payer: Aetna of CA Government/Medicare	$1.58
Rate for Payer: Cash Price	$1.18
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.97

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$2.63

Service Code	NDC 68084-415-01
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.58
Rate for Payer: Aetna of CA Government/Medicare	$1.58
Rate for Payer: Cash Price	$1.18
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.97

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$2.98

Service Code	NDC 51079-767-08
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$2.38
Rate for Payer: Cash Price	$1.34
Rate for Payer: Cigna of CA HMO/PPO	$2.38
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: LLUH Dept of Risk Management WC	$1.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.24

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$1.42

Service Code	NDC 50268-260-11
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.85
Rate for Payer: Aetna of CA Government/Medicare	$0.85
Rate for Payer: Cash Price	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$2.63

Service Code	NDC 68084-415-01
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.18
Rate for Payer: Cigna of CA HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.97

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$2.63

Service Code	NDC 68084-415-11
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.18
Rate for Payer: Cigna of CA HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.97

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$0.86

Service Code	NDC 55111-534-01
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$0.29

Service Code	NDC 65862-595-01
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.22

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$0.29

Service Code	NDC 65862-595-01
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.22

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$0.86

Service Code	NDC 55111-534-01
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$2.98

Service Code	NDC 51079-767-08
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$2.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.79
Rate for Payer: Aetna of CA Government/Medicare	$1.79
Rate for Payer: Cash Price	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.79
Rate for Payer: LLUH Dept of Risk Management WC	$1.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.24

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR [81426]

Facility

$1.42

Service Code	NDC 50268-260-11
Hospital Charge Code	1711851
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.14
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cigna of CA HMO/PPO	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.06

DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION [9892]

Facility

$0.42

Service Code	CPT J1250
Hospital Charge Code	1757187
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION [9892]

Facility

$0.42

Service Code	CPT J1250
Hospital Charge Code	1757187
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS [15981]

Facility

$0.04

Service Code	CPT J1250
Hospital Charge Code	1759122
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS [15981]

Facility

$0.11

Service Code	CPT J1250
Hospital Charge Code	1759122
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV [18315]

Facility

$0.07

Service Code	CPT J1250
Hospital Charge Code	1759123
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
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: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV [18315]

Facility

$0.07

Service Code	CPT J1250
Hospital Charge Code	1759123
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

Know your out-of-pocket cost for care.

All Charges