Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.20

Service Code	NDC 43547-275-03
Hospital Charge Code	1711717
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 5 MG TABLET [18786]

Facility

$0.20

Service Code	NDC 43547-275-03
Hospital Charge Code	1711717
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 5 MG TABLET [18786]

Facility

$0.53

Service Code	NDC 59762-0245-3
Hospital Charge Code	1711717
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.16

Service Code	NDC 0904-6477-61
Hospital Charge Code	1711717
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 5 MG TABLET [18786]

Facility

$0.16

Service Code	NDC 0904-6477-61
Hospital Charge Code	1711717
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 5 MG TABLET [18786]

Facility

$0.18

Service Code	NDC 13668-102-30
Hospital Charge Code	1711717
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.18

Service Code	NDC 13668-102-30
Hospital Charge Code	1711717
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
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: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

DONEPEZIL 5 MG TABLET [18786]

Facility

$0.53

Service Code	NDC 59762-0245-3
Hospital Charge Code	1711717
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION [2595]

Facility

$0.70

Service Code	CPT J1265
Hospital Charge Code	1720516
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION [2595]

Facility

$0.86

Service Code	CPT J1265
Hospital Charge Code	1720516
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]

Facility

$0.07

Service Code	CPT J1265
Hospital Charge Code	1771187
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]

Facility

$0.07

Service Code	CPT J1265
Hospital Charge Code	1771187
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 Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
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: Multiplan Beech St/Commercial/PHCS	$0.05

DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]

Facility

$0.07

Service Code	CPT J1265
Hospital Charge Code	NDC4080662
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 Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
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: Multiplan Beech St/Commercial/PHCS	$0.05

DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]

Facility

$0.07

Service Code	CPT J1265
Hospital Charge Code	NDC4080662
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]

Facility

$0.10

Service Code	CPT J1265
Hospital Charge Code	1771255
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]

Facility

$0.10

Service Code	CPT J1265
Hospital Charge Code	1771255
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]

Facility

$0.10

Service Code	CPT J1265
Hospital Charge Code	NDC4080663
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]

Facility

$0.10

Service Code	CPT J1265
Hospital Charge Code	NDC4080663
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$60.53

Service Code	NDC 50242-100-39
Hospital Charge Code	1744070
Hospital Revenue Code	259
Min. Negotiated Rate	$33.29
Max. Negotiated Rate	$48.42
Rate for Payer: Cash Price	$27.24
Rate for Payer: Cigna of CA HMO/PPO	$48.42
Rate for Payer: Health Smart Auto/Commercial	$36.32
Rate for Payer: LLUH Dept of Risk Management WC	$33.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.40

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$60.53

Service Code	NDC 50242-100-40
Hospital Charge Code	1744070
Hospital Revenue Code	259
Min. Negotiated Rate	$33.29
Max. Negotiated Rate	$48.42
Rate for Payer: Cash Price	$27.24
Rate for Payer: Cigna of CA HMO/PPO	$48.42
Rate for Payer: Health Smart Auto/Commercial	$36.32
Rate for Payer: LLUH Dept of Risk Management WC	$33.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.40

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$60.53

Service Code	NDC 50242-100-39
Hospital Charge Code	1744070
Hospital Revenue Code	259
Min. Negotiated Rate	$33.29
Max. Negotiated Rate	$45.40
Rate for Payer: Health Smart Auto/Commercial	$36.32
Rate for Payer: Cash Price	$27.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.32
Rate for Payer: Aetna of CA Government/Medicare	$36.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.32
Rate for Payer: LLUH Dept of Risk Management WC	$33.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.40

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]

Facility

$60.53

Service Code	NDC 50242-100-40
Hospital Charge Code	1744070
Hospital Revenue Code	259
Min. Negotiated Rate	$33.29
Max. Negotiated Rate	$45.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.32
Rate for Payer: Aetna of CA Government/Medicare	$36.32
Rate for Payer: Cash Price	$27.24
Rate for Payer: Health Smart Auto/Commercial	$36.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.32
Rate for Payer: LLUH Dept of Risk Management WC	$33.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.40

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$6.00

Service Code	NDC 50383-233-10
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$6.00

Service Code	NDC 24208-486-10
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]

Facility

$2.40

Service Code	NDC 61314-030-02
Hospital Charge Code	1740314
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

Know your out-of-pocket cost for care.

All Charges