Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$22.06

Service Code	NDC 0378-6470-97
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$17.65
Rate for Payer: Cash Price	$12.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.65
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Commercial	$16.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 45802-580-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 42858-150-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.84
Rate for Payer: Aetna of CA Government/Medicare	$6.84
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 42858-150-91
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 45802-580-84
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.84
Rate for Payer: Aetna of CA Government/Medicare	$6.84
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$22.06

Service Code	NDC 0378-6470-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$17.65
Rate for Payer: Cash Price	$12.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.65
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Commercial	$16.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 42858-150-91
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.84
Rate for Payer: Aetna of CA Government/Medicare	$6.84
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 45802-580-84
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$22.06

Service Code	NDC 0378-6470-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$17.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.24
Rate for Payer: Aetna of CA Government/Medicare	$13.24
Rate for Payer: Cash Price	$12.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.65
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Commercial	$16.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$22.06

Service Code	NDC 0378-6470-97
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$17.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.24
Rate for Payer: Aetna of CA Government/Medicare	$13.24
Rate for Payer: Cash Price	$12.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.65
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Commercial	$16.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$19.39

Service Code	NDC 0378-6470-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$15.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.63
Rate for Payer: Aetna of CA Government/Medicare	$11.63
Rate for Payer: Cash Price	$10.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.51
Rate for Payer: Health Smart Auto/Commercial	$11.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.63
Rate for Payer: LLUH Dept of Risk Management WC	$10.66
Rate for Payer: Multiplan Commercial	$14.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 42858-150-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$11.40

Service Code	NDC 45802-580-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.84
Rate for Payer: Aetna of CA Government/Medicare	$6.84
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

$19.39

Service Code	NDC 0378-6470-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$15.51
Rate for Payer: Cash Price	$10.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.51
Rate for Payer: Health Smart Auto/Commercial	$11.63
Rate for Payer: LLUH Dept of Risk Management WC	$10.66
Rate for Payer: Multiplan Commercial	$14.54

SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]

Facility

$630.00

Service Code	HCPCS J2850
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$504.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$504.00
Rate for Payer: Health Smart Auto/Commercial	$378.00
Rate for Payer: LLUH Dept of Risk Management WC	$346.50
Rate for Payer: Multiplan Commercial	$472.50

SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]

Facility

$630.00

Service Code	HCPCS J2850
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$378.00
Rate for Payer: Aetna of CA Government/Medicare	$378.00
Rate for Payer: Cash Price	$346.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$504.00
Rate for Payer: Health Smart Auto/Commercial	$378.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$378.00
Rate for Payer: LLUH Dept of Risk Management WC	$346.50
Rate for Payer: Multiplan Commercial	$472.50

SELEGILINE 5 MG CAPSULE [17280]

Facility

$2.01

Service Code	NDC 60505-0055-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

SELEGILINE 5 MG CAPSULE [17280]

Facility

$2.01

Service Code	NDC 60505-0055-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

SELENIUM 200 MCG TABLET [7139]

Facility

$0.06

Service Code	NDC 4009310196
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

SELENIUM 200 MCG TABLET [7139]

Facility

$0.06

Service Code	NDC 4009310196
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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 Commercial	$0.05

SELENIUM 200 MCG TABLET [7139]

Facility

$0.06

Service Code	NDC 7985401163
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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 Commercial	$0.05

SELENIUM 200 MCG TABLET [7139]

Facility

$0.06

Service Code	NDC 7985401163
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

SELENIUM 200 MCG TABLET [7139]

Facility

$0.06

Service Code	NDC 7431203201
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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 Commercial	$0.05

SELENIUM 200 MCG TABLET [7139]

Facility

$0.06

Service Code	NDC 7431203201
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

SELENIUM 50 MCG TABLET [7140]

Facility

$0.05

Service Code	NDC 26899-721-74
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

Know your out-of-pocket cost for care.

All Charges