Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]

Facility

$31.60

Service Code	NDC 63323-130-11
Hospital Revenue Code	250
Min. Negotiated Rate	$17.38
Max. Negotiated Rate	$23.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.96
Rate for Payer: Aetna of CA Government/Medicare	$18.96
Rate for Payer: Cash Price	$14.22
Rate for Payer: Health Smart Auto/Commercial	$18.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.96
Rate for Payer: LLUH Dept of Risk Management WC	$17.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.70

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION FOR SCLEROSIS [4082622]

Facility

$25.20

Service Code	NDC 63323-130-17
Hospital Revenue Code	250
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$20.16
Rate for Payer: Cash Price	$11.34
Rate for Payer: Cigna of CA HMO/PPO	$20.16
Rate for Payer: Health Smart Auto/Commercial	$15.12
Rate for Payer: LLUH Dept of Risk Management WC	$13.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.90

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$0.24

Service Code	NDC 42806-312-50
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.29

Service Code	NDC 50268-279-11
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.57
Rate for Payer: Aetna of CA Government/Medicare	$2.57
Rate for Payer: Cash Price	$1.93
Rate for Payer: Health Smart Auto/Commercial	$2.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.57
Rate for Payer: LLUH Dept of Risk Management WC	$2.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.22

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.29

Service Code	NDC 50268-279-15
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$1.93
Rate for Payer: Cigna of CA HMO/PPO	$3.43
Rate for Payer: Health Smart Auto/Commercial	$2.57
Rate for Payer: LLUH Dept of Risk Management WC	$2.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.22

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$0.24

Service Code	NDC 42806-312-50
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$2.62

Service Code	NDC 0904-0430-06
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.57
Rate for Payer: Aetna of CA Government/Medicare	$1.57
Rate for Payer: Cash Price	$1.18
Rate for Payer: Health Smart Auto/Commercial	$1.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.57
Rate for Payer: LLUH Dept of Risk Management WC	$1.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.96

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$2.62

Service Code	NDC 0904-0430-06
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.18
Rate for Payer: Cigna of CA HMO/PPO	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.57
Rate for Payer: LLUH Dept of Risk Management WC	$1.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.96

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.35

Service Code	NDC 0904-0430-04
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$3.48
Rate for Payer: Cash Price	$1.96
Rate for Payer: Cigna of CA HMO/PPO	$3.48
Rate for Payer: Health Smart Auto/Commercial	$2.61
Rate for Payer: LLUH Dept of Risk Management WC	$2.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.26

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.29

Service Code	NDC 50268-279-11
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.43
Rate for Payer: Cash Price	$1.93
Rate for Payer: Cigna of CA HMO/PPO	$3.43
Rate for Payer: Health Smart Auto/Commercial	$2.57
Rate for Payer: LLUH Dept of Risk Management WC	$2.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.22

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.29

Service Code	NDC 50268-279-15
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.57
Rate for Payer: Aetna of CA Government/Medicare	$2.57
Rate for Payer: Cash Price	$1.93
Rate for Payer: Health Smart Auto/Commercial	$2.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.57
Rate for Payer: LLUH Dept of Risk Management WC	$2.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.22

DOXYCYCLINE HYCLATE 100 MG TABLET [2625]

Facility

$4.35

Service Code	NDC 0904-0430-04
Hospital Charge Code	ERX2625
Hospital Revenue Code	259
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$3.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.61
Rate for Payer: Aetna of CA Government/Medicare	$2.61
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Smart Auto/Commercial	$2.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.61
Rate for Payer: LLUH Dept of Risk Management WC	$2.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.26

DOXYCYCLINE HYCLATE 50 MG CAPSULE [2624]

Facility

$0.34

Service Code	NDC 0143-9802-50
Hospital Charge Code	1711308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

DOXYCYCLINE HYCLATE 50 MG CAPSULE [2624]

Facility

$0.34

Service Code	NDC 0143-9802-50
Hospital Charge Code	1711308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
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	$0.15
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 Beech St/Commercial/PHCS	$0.26

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 68084-743-21
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.79

Service Code	NDC 68084-743-32
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.43
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.79

Service Code	NDC 68084-743-32
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-21
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-21
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.01

Service Code	NDC 68382-707-18
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.76
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	$0.45
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	$0.76

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 60687-716-11
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 68084-743-11
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.28

Service Code	NDC 68084-743-11
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.02
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.96

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.79

Service Code	NDC 68084-743-33
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.43
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.43
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE [9900]

Facility

$1.79

Service Code	NDC 68084-743-33
Hospital Charge Code	ERX9900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

Know your out-of-pocket cost for care.

All Charges