Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DRONABINOL 5 MG CAPSULE [9905]

Facility

$11.57

Service Code	NDC 0904-6746-04
Hospital Charge Code	1730005
Hospital Revenue Code	636
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$8.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.94
Rate for Payer: Aetna of CA Government/Medicare	$6.94
Rate for Payer: Cash Price	$5.21
Rate for Payer: Health Smart Auto/Commercial	$6.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.94
Rate for Payer: LLUH Dept of Risk Management WC	$6.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.68

DRONABINOL 5 MG CAPSULE [9905]

Facility

$11.77

Service Code	NDC 60687-386-21
Hospital Charge Code	1730005
Hospital Revenue Code	636
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$9.42
Rate for Payer: Cash Price	$5.30
Rate for Payer: Cigna of CA HMO/PPO	$9.42
Rate for Payer: Health Smart Auto/Commercial	$7.06
Rate for Payer: LLUH Dept of Risk Management WC	$6.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.83

DRONABINOL 5 MG CAPSULE [9905]

Facility

$11.57

Service Code	NDC 0904-6746-04
Hospital Charge Code	1730005
Hospital Revenue Code	636
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$9.26
Rate for Payer: Cash Price	$5.21
Rate for Payer: Cigna of CA HMO/PPO	$9.26
Rate for Payer: Health Smart Auto/Commercial	$6.94
Rate for Payer: LLUH Dept of Risk Management WC	$6.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.68

DRONABINOL 5 MG CAPSULE [9905]

Facility

$11.77

Service Code	NDC 60687-386-11
Hospital Charge Code	1730005
Hospital Revenue Code	636
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$9.42
Rate for Payer: Cash Price	$5.30
Rate for Payer: Cigna of CA HMO/PPO	$9.42
Rate for Payer: Health Smart Auto/Commercial	$7.06
Rate for Payer: LLUH Dept of Risk Management WC	$6.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.83

DRONEDARONE 400 MG TABLET [98329]

Facility

$15.20

Service Code	NDC 0024-4142-60
Hospital Charge Code	1712418
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$11.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.12
Rate for Payer: Aetna of CA Government/Medicare	$9.12
Rate for Payer: Cash Price	$6.84
Rate for Payer: Health Smart Auto/Commercial	$9.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.40

DRONEDARONE 400 MG TABLET [98329]

Facility

$15.20

Service Code	NDC 0024-4142-60
Hospital Charge Code	1712418
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$12.16
Rate for Payer: Cash Price	$6.84
Rate for Payer: Cigna of CA HMO/PPO	$12.16
Rate for Payer: Health Smart Auto/Commercial	$9.12
Rate for Payer: LLUH Dept of Risk Management WC	$8.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.40

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]

Facility

$5.37

Service Code	CPT J1790
Hospital Charge Code	NDG2654
Hospital Revenue Code	636
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$4.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.22
Rate for Payer: Aetna of CA Government/Medicare	$3.22
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Smart Auto/Commercial	$3.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.03

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [2654]

Facility

$5.37

Service Code	CPT J1790
Hospital Charge Code	NDG2654
Hospital Revenue Code	636
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$4.30
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cigna of CA HMO/PPO	$4.30
Rate for Payer: Health Smart Auto/Commercial	$3.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.03

DROXIDOPA 100 MG CAPSULE [206920]

Facility

$1.66

Service Code	NDC 0054-0532-22
Hospital Charge Code	ERX206920
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna of CA HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

DROXIDOPA 100 MG CAPSULE [206920]

Facility

$1.66

Service Code	NDC 0054-0532-22
Hospital Charge Code	ERX206920
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.00
Rate for Payer: Aetna of CA Government/Medicare	$1.00
Rate for Payer: Cash Price	$0.75
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.24

DTAP-POLIO-HIB CONJ-TET(PF) 15 LF-48MCG-5 LF-62 DU-10MCG/ 0.5ML IM KIT [227486]

Facility

$129.06

Service Code	CPT 90698
Hospital Charge Code	ERX227486
Hospital Revenue Code	636
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$103.25
Rate for Payer: Cash Price	$58.08
Rate for Payer: Cigna of CA HMO/PPO	$103.25
Rate for Payer: Health Smart Auto/Commercial	$77.44
Rate for Payer: LLUH Dept of Risk Management WC	$70.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$96.80

DTAP-POLIO-HIB CONJ-TET(PF) 15 LF-48MCG-5 LF-62 DU-10MCG/ 0.5ML IM KIT [227486]

Facility

$129.06

Service Code	CPT 90698
Hospital Charge Code	ERX227486
Hospital Revenue Code	636
Min. Negotiated Rate	$70.98
Max. Negotiated Rate	$96.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$77.44
Rate for Payer: Aetna of CA Government/Medicare	$77.44
Rate for Payer: Cash Price	$58.08
Rate for Payer: Health Smart Auto/Commercial	$77.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$77.44
Rate for Payer: LLUH Dept of Risk Management WC	$70.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$96.80

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.36

Service Code	NDC 51991-746-90
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
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	$0.16
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 Beech St/Commercial/PHCS	$0.27

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.56

Service Code	NDC 68001-413-06
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.42

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.56

Service Code	NDC 68001-413-06
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.42

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$2.12

Service Code	NDC 68084-675-11
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cigna of CA HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.59

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.59

Service Code	NDC 60505-2995-6
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
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	$0.27
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 Beech St/Commercial/PHCS	$0.44

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.59

Service Code	NDC 60505-2995-6
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.44

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$0.36

Service Code	NDC 51991-746-90
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.27

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$2.12

Service Code	NDC 68084-675-11
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.59

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$2.12

Service Code	NDC 68084-675-21
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.59

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

$2.12

Service Code	NDC 68084-675-21
Hospital Charge Code	1711839
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cigna of CA HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.59

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$0.20

Service Code	NDC 67877-264-30
Hospital Charge Code	1711840
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

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$1.47

Service Code	NDC 50268-287-13
Hospital Charge Code	1711840
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cigna of CA HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.10

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

$1.47

Service Code	NDC 50268-287-11
Hospital Charge Code	1711840
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.18
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cigna of CA HMO/PPO	$1.18
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.10

Know your out-of-pocket cost for care.

All Charges