Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

$0.28

Service Code	NDC 4116700609
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

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: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.19
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: 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

DRONABINOL 2.5 MG CAPSULE [9904]

Facility

$2.23

Service Code	NDC 67877-753-60
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.67

DRONABINOL 2.5 MG CAPSULE [9904]

Facility

$2.23

Service Code	NDC 67877-753-60
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.78
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.67

DRONABINOL 5 MG CAPSULE [9905]

Facility

$20.63

Service Code	NDC 0904-7145-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.35
Max. Negotiated Rate	$16.50
Rate for Payer: Cash Price	$11.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.50
Rate for Payer: Health Smart Auto/Commercial	$12.38
Rate for Payer: LLUH Dept of Risk Management WC	$11.35
Rate for Payer: Multiplan Commercial	$15.47

DRONABINOL 5 MG CAPSULE [9905]

Facility

$4.12

Service Code	NDC 67877-754-60
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	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.09

DRONABINOL 5 MG CAPSULE [9905]

Facility

$20.63

Service Code	NDC 0904-7145-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.35
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.38
Rate for Payer: Aetna of CA Government/Medicare	$12.38
Rate for Payer: Cash Price	$11.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.50
Rate for Payer: Health Smart Auto/Commercial	$12.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.38
Rate for Payer: LLUH Dept of Risk Management WC	$11.35
Rate for Payer: Multiplan Commercial	$15.47

DRONABINOL 5 MG CAPSULE [9905]

Facility

$4.12

Service Code	NDC 67877-754-60
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	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.47
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	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.09

DRONEDARONE 400 MG TABLET [98329]

Facility

$16.20

Service Code	NDC 0024-4142-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Cash Price	$8.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Commercial	$12.15

DRONEDARONE 400 MG TABLET [98329]

Facility

$16.20

Service Code	NDC 0024-4142-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$12.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.72
Rate for Payer: Aetna of CA Government/Medicare	$9.72
Rate for Payer: Cash Price	$8.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.96
Rate for Payer: Health Smart Auto/Commercial	$9.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.91
Rate for Payer: Multiplan Commercial	$12.15

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]

Facility

$6.38

Service Code	HCPCS J1790
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.83
Rate for Payer: LLUH Dept of Risk Management WC	$3.51
Rate for Payer: Multiplan Commercial	$4.79

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]

Facility

$6.38

Service Code	HCPCS J1790
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$5.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.83
Rate for Payer: Aetna of CA Government/Medicare	$3.83
Rate for Payer: Cash Price	$3.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.83
Rate for Payer: LLUH Dept of Risk Management WC	$3.51
Rate for Payer: Multiplan Commercial	$4.79

DROXIDOPA 100 MG CAPSULE [206920]

Facility

$1.66

Service Code	NDC 0054-0532-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.00
Rate for Payer: Aetna of CA Government/Medicare	$1.00
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Commercial	$1.25

DROXIDOPA 100 MG CAPSULE [206920]

Facility

$1.66

Service Code	NDC 0054-0532-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Commercial	$1.25

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.56

Service Code	NDC 68001-413-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.56

Service Code	NDC 68001-413-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.56

Service Code	NDC 68001-594-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.56

Service Code	NDC 68001-594-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.36

Service Code	NDC 51991-746-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.36

Service Code	NDC 51991-746-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$0.57

Service Code	NDC 68001-595-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$0.56

Service Code	NDC 68001-595-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$0.56

Service Code	NDC 68001-595-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.42

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$0.57

Service Code	NDC 68001-595-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

Know your out-of-pocket cost for care.

All Charges