Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.22

Service Code	NDC 0121-1870-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.14

Service Code	NDC 0904-7279-66
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.22

Service Code	NDC 0121-1870-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.13

Service Code	NDC 9993-6962-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.14

Service Code	NDC 0904-7279-72
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.22

Service Code	NDC 0121-1870-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [36962]

Facility

$0.14

Service Code	NDC 0904-7279-72
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

DOCUSATE SODIUM 50 MG CAPSULE [2568]

Facility

$0.31

Service Code	NDC 6761811128
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
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	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
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	$0.17
Rate for Payer: Multiplan Commercial	$0.23

DOCUSATE SODIUM 50 MG CAPSULE [2568]

Facility

$0.31

Service Code	NDC 6761811128
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$0.40

Service Code	NDC 69452-131-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$1.92

Service Code	NDC 47335-061-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
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	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
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 Commercial	$1.44

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$0.40

Service Code	NDC 69452-131-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$1.92

Service Code	NDC 47335-061-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.44

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.00

Service Code	NDC 59762-0038-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
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	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
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 Commercial	$3.75

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.70

Service Code	NDC 0069-5810-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.42
Rate for Payer: Aetna of CA Government/Medicare	$3.42
Rate for Payer: Cash Price	$3.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.56
Rate for Payer: Health Smart Auto/Commercial	$3.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Commercial	$4.28

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$1.92

Service Code	NDC 47335-062-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.44

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.00

Service Code	NDC 59762-0038-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$1.60

Service Code	NDC 59651-119-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.28
Rate for Payer: Health Smart Auto/Commercial	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$1.20

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.40

Service Code	NDC 69452-132-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.70

Service Code	NDC 0069-5810-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$4.56
Rate for Payer: Cash Price	$3.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.56
Rate for Payer: Health Smart Auto/Commercial	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$3.13
Rate for Payer: Multiplan Commercial	$4.28

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.40

Service Code	NDC 69452-132-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$1.92

Service Code	NDC 47335-062-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
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	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
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 Commercial	$1.44

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.40

Service Code	NDC 72205-040-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$1.60

Service Code	NDC 59651-119-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.96
Rate for Payer: Aetna of CA Government/Medicare	$0.96
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.28
Rate for Payer: Health Smart Auto/Commercial	$0.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$1.20

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.40

Service Code	NDC 72205-040-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

Know your out-of-pocket cost for care.

All Charges