Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]

Facility

$0.49

Service Code	NDC 17433-9876-5
Hospital Charge Code	1712497
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

DOCUSATE SODIUM 283 MG/5 ML ENEMA [188885]

Facility

$0.45

Service Code	NDC 17433-9876-0
Hospital Charge Code	1712497
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

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

Facility

$0.15

Service Code	NDC 0121-1870-10
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$0.13

Service Code	NDC 9993-6962-00
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.10

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

Facility

$0.15

Service Code	NDC 0121-1870-00
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$0.13

Service Code	NDC 9993-6962-00
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.06
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	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

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

Facility

$0.06

Service Code	NDC 50383-349-10
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
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	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

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

Facility

$0.06

Service Code	NDC 50383-349-11
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
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	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

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

Facility

$0.06

Service Code	NDC 50383-349-11
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

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

Facility

$0.15

Service Code	NDC 0121-1870-00
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$0.15

Service Code	NDC 0121-1870-10
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$0.06

Service Code	NDC 50383-349-10
Hospital Charge Code	1716060
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

DOCUSATE SODIUM 50 MG CAPSULE [2568]

Facility

$0.31

Service Code	NDC 6761811128
Hospital Charge Code	1710831
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.23

DOCUSATE SODIUM 50 MG CAPSULE [2568]

Facility

$0.31

Service Code	NDC 6761811128
Hospital Charge Code	1710831
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
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	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

DOCUSATE SODIUM ORAL SOLUTION 10 MG/ML [4080924]

Facility

$0.01

Service Code	NDC 50383-771-16
Hospital Charge Code	1715622
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

DOCUSATE SODIUM ORAL SOLUTION 10 MG/ML [4080924]

Facility

$0.01

Service Code	NDC 50383-771-16
Hospital Charge Code	1715622
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$1.92

Service Code	NDC 47335-061-86
Hospital Charge Code	1710914
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.44
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	$0.86
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 Beech St/Commercial/PHCS	$1.44

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$1.92

Service Code	NDC 47335-061-86
Hospital Charge Code	1710914
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

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$0.91

Service Code	NDC 69452-131-17
Hospital Charge Code	1710914
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

DOFETILIDE 125 MCG CAPSULE [26965]

Facility

$0.91

Service Code	NDC 69452-131-17
Hospital Charge Code	1710914
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.00

Service Code	NDC 59762-0038-2
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
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	$2.25
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 Beech St/Commercial/PHCS	$3.75

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.00

Service Code	NDC 59762-0038-2
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.75

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.70

Service Code	NDC 0069-5810-61
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.56
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cigna of CA HMO/PPO	$4.56
Rate for Payer: Health Smart Auto/Commercial	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$5.70

Service Code	NDC 0069-5810-61
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.28
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	$2.57
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	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

DOFETILIDE 250 MCG CAPSULE [26966]

Facility

$0.91

Service Code	NDC 69452-132-17
Hospital Charge Code	1710915
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

Know your out-of-pocket cost for care.

All Charges