Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.91

Service Code	NDC 69452-132-17
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$1.92

Service Code	NDC 47335-062-86
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.44

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.70

Service Code	NDC 0069-5810-61
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.56
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cigna of CA HMO/PPO	$4.56
Rate for Payer: Health Smart Auto/Commercial	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.91

Service Code	NDC 69452-132-17
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.00

Service Code	NDC 59762-0038-2
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$1.92

Service Code	NDC 47335-063-86
Hospital Charge Code	1710916
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.44
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	$0.86
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 Beech St/Commercial/PHCS	$1.44

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$13.17

Service Code	NDC 0069-5820-43
Hospital Charge Code	1710916
Hospital Revenue Code	259
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$10.54
Rate for Payer: Cash Price	$5.93
Rate for Payer: Cigna of CA HMO/PPO	$10.54
Rate for Payer: Health Smart Auto/Commercial	$7.90
Rate for Payer: LLUH Dept of Risk Management WC	$7.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.88

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$13.17

Service Code	NDC 0069-5820-61
Hospital Charge Code	1710916
Hospital Revenue Code	259
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.90
Rate for Payer: Aetna of CA Government/Medicare	$7.90
Rate for Payer: Cash Price	$5.93
Rate for Payer: Health Smart Auto/Commercial	$7.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.90
Rate for Payer: LLUH Dept of Risk Management WC	$7.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.88

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$13.17

Service Code	NDC 0069-5820-61
Hospital Charge Code	1710916
Hospital Revenue Code	259
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$10.54
Rate for Payer: Cash Price	$5.93
Rate for Payer: Cigna of CA HMO/PPO	$10.54
Rate for Payer: Health Smart Auto/Commercial	$7.90
Rate for Payer: LLUH Dept of Risk Management WC	$7.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.88

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$1.92

Service Code	NDC 47335-063-86
Hospital Charge Code	1710916
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.44

DOFETILIDE 500 MCG CAPSULE [26967]

Facility

$13.17

Service Code	NDC 0069-5820-43
Hospital Charge Code	1710916
Hospital Revenue Code	259
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$9.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.90
Rate for Payer: Aetna of CA Government/Medicare	$7.90
Rate for Payer: Cash Price	$5.93
Rate for Payer: Health Smart Auto/Commercial	$7.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.90
Rate for Payer: LLUH Dept of Risk Management WC	$7.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.88

DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]

Facility

$132.61

Service Code	NDC 49702-242-13
Hospital Charge Code	ERX220407
Hospital Revenue Code	259
Min. Negotiated Rate	$72.94
Max. Negotiated Rate	$106.09
Rate for Payer: Cash Price	$59.67
Rate for Payer: Cigna of CA HMO/PPO	$106.09
Rate for Payer: Health Smart Auto/Commercial	$79.57
Rate for Payer: LLUH Dept of Risk Management WC	$72.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$99.46

DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET [220407]

Facility

$132.61

Service Code	NDC 49702-242-13
Hospital Charge Code	ERX220407
Hospital Revenue Code	259
Min. Negotiated Rate	$72.94
Max. Negotiated Rate	$99.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$79.57
Rate for Payer: Aetna of CA Government/Medicare	$79.57
Rate for Payer: Cash Price	$59.67
Rate for Payer: Health Smart Auto/Commercial	$79.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$79.57
Rate for Payer: LLUH Dept of Risk Management WC	$72.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$99.46

DOLUTEGRAVIR 50 MG TABLET [201546]

Facility

$85.23

Service Code	NDC 49702-228-13
Hospital Charge Code	ERX201546
Hospital Revenue Code	259
Min. Negotiated Rate	$46.88
Max. Negotiated Rate	$63.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.14
Rate for Payer: Aetna of CA Government/Medicare	$51.14
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Smart Auto/Commercial	$51.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.14
Rate for Payer: LLUH Dept of Risk Management WC	$46.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.92

DOLUTEGRAVIR 50 MG TABLET [201546]

Facility

$85.23

Service Code	NDC 49702-228-13
Hospital Charge Code	ERX201546
Hospital Revenue Code	259
Min. Negotiated Rate	$46.88
Max. Negotiated Rate	$68.18
Rate for Payer: Cash Price	$38.35
Rate for Payer: Cigna of CA HMO/PPO	$68.18
Rate for Payer: Health Smart Auto/Commercial	$51.14
Rate for Payer: LLUH Dept of Risk Management WC	$46.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.92

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.20

Service Code	NDC 43547-276-03
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.09

Service Code	NDC 59746-330-30
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 0904-6478-61
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-11
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 0904-6478-61
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-01
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-01
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.20

Service Code	NDC 43547-276-03
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.09

Service Code	NDC 59746-330-30
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

DONEPEZIL 10 MG TABLET [18787]

Facility

$0.16

Service Code	NDC 60687-303-11
Hospital Charge Code	1711716
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

Know your out-of-pocket cost for care.

All Charges