Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$3.83

Service Code	NDC 82584-604-30
Hospital Charge Code	ERX191035
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$1.72
Rate for Payer: Cigna of CA HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.87

DORZOLAMIDE-TIMOLOL (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE [154283]

Facility

$1.92

Service Code	NDC 50742-323-60
Hospital Charge Code	ERX191035
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

DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [231227]

Facility

$1,333.69

Service Code	CPT J9272
Hospital Charge Code	NDG231227
Hospital Revenue Code	636
Min. Negotiated Rate	$733.53
Max. Negotiated Rate	$1,000.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$800.21
Rate for Payer: Aetna of CA Government/Medicare	$800.21
Rate for Payer: Cash Price	$600.16
Rate for Payer: Health Smart Auto/Commercial	$800.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$800.21
Rate for Payer: LLUH Dept of Risk Management WC	$733.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,000.27

DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [231227]

Facility

$1,333.69

Service Code	CPT J9272
Hospital Charge Code	NDG231227
Hospital Revenue Code	636
Min. Negotiated Rate	$733.53
Max. Negotiated Rate	$1,066.95
Rate for Payer: Cash Price	$600.16
Rate for Payer: Cigna of CA HMO/PPO	$1,066.95
Rate for Payer: Health Smart Auto/Commercial	$800.21
Rate for Payer: LLUH Dept of Risk Management WC	$733.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,000.27

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.09

Service Code	NDC 68084-836-01
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.02

Service Code	NDC 68084-836-95
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.09

Service Code	NDC 68084-836-11
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.02

Service Code	NDC 68084-836-25
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 1 MG TABLET [9894]

Facility

$0.51

Service Code	NDC 60505-0093-0
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.09

Service Code	NDC 68084-836-11
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

DOXAZOSIN 1 MG TABLET [9894]

Facility

$0.51

Service Code	NDC 60505-0093-0
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.09

Service Code	NDC 68084-836-01
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.02

Service Code	NDC 68084-836-95
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 1 MG TABLET [9894]

Facility

$1.02

Service Code	NDC 68084-836-25
Hospital Charge Code	1711544
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 2 MG TABLET [9895]

Facility

$0.51

Service Code	NDC 60505-0094-0
Hospital Charge Code	1712210
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DOXAZOSIN 2 MG TABLET [9895]

Facility

$1.02

Service Code	NDC 68084-851-95
Hospital Charge Code	1712210
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 2 MG TABLET [9895]

Facility

$1.02

Service Code	NDC 68084-851-25
Hospital Charge Code	1712210
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 2 MG TABLET [9895]

Facility

$1.02

Service Code	NDC 68084-851-95
Hospital Charge Code	1712210
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 2 MG TABLET [9895]

Facility

$0.51

Service Code	NDC 60505-0094-0
Hospital Charge Code	1712210
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DOXAZOSIN 2 MG TABLET [9895]

Facility

$1.02

Service Code	NDC 68084-851-25
Hospital Charge Code	1712210
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 4 MG TABLET [9896]

Facility

$0.32

Service Code	NDC 16729-213-01
Hospital Charge Code	1712422
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

DOXAZOSIN 4 MG TABLET [9896]

Facility

$1.03

Service Code	NDC 68084-862-95
Hospital Charge Code	1712422
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 4 MG TABLET [9896]

Facility

$1.03

Service Code	NDC 68084-862-95
Hospital Charge Code	1712422
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 4 MG TABLET [9896]

Facility

$1.03

Service Code	NDC 68084-862-25
Hospital Charge Code	1712422
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

DOXAZOSIN 4 MG TABLET [9896]

Facility

$1.03

Service Code	NDC 68084-862-25
Hospital Charge Code	1712422
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

Know your out-of-pocket cost for care.

All Charges