Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$1.92

Service Code	NDC 60687-745-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$1.92

Service Code	NDC 60687-745-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.40

Service Code	NDC 57237-019-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.40

Service Code	NDC 57237-019-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.36

Service Code	NDC 68001-415-04
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 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.59

Service Code	NDC 43547-381-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$1.92

Service Code	NDC 60687-745-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.36

Service Code	NDC 68001-596-04
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 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.59

Service Code	NDC 43547-381-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.36

Service Code	NDC 27241-099-03
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 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.36

Service Code	NDC 27241-099-03
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 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.36

Service Code	NDC 68001-415-04
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 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$0.36

Service Code	NDC 68001-596-04
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 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

$1.92

Service Code	NDC 60687-745-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE SPRINKLE [225947]

Facility

$8.95

Service Code	NDC 47335-619-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$7.16
Rate for Payer: Cash Price	$4.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.16
Rate for Payer: Health Smart Auto/Commercial	$5.37
Rate for Payer: LLUH Dept of Risk Management WC	$4.92
Rate for Payer: Multiplan Commercial	$6.71

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE SPRINKLE [225947]

Facility

$8.95

Service Code	NDC 47335-619-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$7.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.37
Rate for Payer: Aetna of CA Government/Medicare	$5.37
Rate for Payer: Cash Price	$4.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.16
Rate for Payer: Health Smart Auto/Commercial	$5.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.37
Rate for Payer: LLUH Dept of Risk Management WC	$4.92
Rate for Payer: Multiplan Commercial	$6.71

DURLOBACTAM 0.5 GRAM INTRAVENOUS SOLUTION [241588]

Facility

$199.60

Service Code	NDC 68547-311-30
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$109.78
Max. Negotiated Rate	$159.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.76
Rate for Payer: Aetna of CA Government/Medicare	$119.76
Rate for Payer: Cash Price	$109.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.68
Rate for Payer: Health Smart Auto/Commercial	$119.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.76
Rate for Payer: LLUH Dept of Risk Management WC	$109.78
Rate for Payer: Multiplan Commercial	$149.70

DURLOBACTAM 0.5 GRAM INTRAVENOUS SOLUTION [241588]

Facility

$199.60

Service Code	NDC 68547-311-30
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$109.78
Max. Negotiated Rate	$159.68
Rate for Payer: Cash Price	$109.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.68
Rate for Payer: Health Smart Auto/Commercial	$119.76
Rate for Payer: LLUH Dept of Risk Management WC	$109.78
Rate for Payer: Multiplan Commercial	$149.70

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]

Facility

$515.36

Service Code	HCPCS J9173
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$283.45
Max. Negotiated Rate	$412.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$309.22
Rate for Payer: Aetna of CA Government/Medicare	$309.22
Rate for Payer: Cash Price	$283.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$412.29
Rate for Payer: Health Smart Auto/Commercial	$309.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$309.22
Rate for Payer: LLUH Dept of Risk Management WC	$283.45
Rate for Payer: Multiplan Commercial	$386.52

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]

Facility

$515.36

Service Code	HCPCS J9173
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$283.45
Max. Negotiated Rate	$412.29
Rate for Payer: Cash Price	$283.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$412.29
Rate for Payer: Health Smart Auto/Commercial	$309.22
Rate for Payer: LLUH Dept of Risk Management WC	$283.45
Rate for Payer: Multiplan Commercial	$386.52

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$0.38

Service Code	NDC 42806-549-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$0.44

Service Code	NDC 31722-131-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$0.44

Service Code	NDC 31722-131-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
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	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
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 Commercial	$0.33

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

$0.38

Service Code	NDC 42806-549-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]

Facility

$2.00

Service Code	NDC 51672-1303-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

Know your out-of-pocket cost for care.

All Charges