Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]

Facility

$41.16

Service Code	NDC 0517-6560-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$32.93
Rate for Payer: Cash Price	$22.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.93
Rate for Payer: Health Smart Auto/Commercial	$24.70
Rate for Payer: LLUH Dept of Risk Management WC	$22.64
Rate for Payer: Multiplan Commercial	$30.87

SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]

Facility

$41.16

Service Code	NDC 0517-6560-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$32.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.70
Rate for Payer: Aetna of CA Government/Medicare	$24.70
Rate for Payer: Cash Price	$22.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.93
Rate for Payer: Health Smart Auto/Commercial	$24.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.70
Rate for Payer: LLUH Dept of Risk Management WC	$22.64
Rate for Payer: Multiplan Commercial	$30.87

SELENIUM SULFIDE 1 % SHAMPOO [38961]

Facility

$0.02

Service Code	NDC 0536-1995-53
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
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: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
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 Commercial	$0.02

SELENIUM SULFIDE 1 % SHAMPOO [38961]

Facility

$0.02

Service Code	NDC 0536-1995-53
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

SELENIUM SULFIDE 2.25 % SHAMPOO [40158]

Facility

$0.75

Service Code	NDC 42192-152-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

SELENIUM SULFIDE 2.25 % SHAMPOO [40158]

Facility

$0.75

Service Code	NDC 42192-152-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

SELEXIPAG 200 MCG TABLET [212415]

Facility

$306.97

Service Code	HCPCS C9399
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$168.83
Max. Negotiated Rate	$245.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$184.18
Rate for Payer: Aetna of CA Government/Medicare	$184.18
Rate for Payer: Cash Price	$168.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$245.58
Rate for Payer: Health Smart Auto/Commercial	$184.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$184.18
Rate for Payer: LLUH Dept of Risk Management WC	$168.83
Rate for Payer: Multiplan Commercial	$230.23

SELEXIPAG 200 MCG TABLET [212415]

Facility

$306.97

Service Code	HCPCS C9399
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$168.83
Max. Negotiated Rate	$245.58
Rate for Payer: Cash Price	$168.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$245.58
Rate for Payer: Health Smart Auto/Commercial	$184.18
Rate for Payer: LLUH Dept of Risk Management WC	$168.83
Rate for Payer: Multiplan Commercial	$230.23

SELEXIPAG 400 MCG TABLET [212416]

Facility

$477.38

Service Code	HCPCS C9399
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$262.56
Max. Negotiated Rate	$381.90
Rate for Payer: Cash Price	$262.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$381.90
Rate for Payer: Health Smart Auto/Commercial	$286.43
Rate for Payer: LLUH Dept of Risk Management WC	$262.56
Rate for Payer: Multiplan Commercial	$358.04

SELEXIPAG 400 MCG TABLET [212416]

Facility

$477.38

Service Code	HCPCS C9399
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$262.56
Max. Negotiated Rate	$381.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$286.43
Rate for Payer: Aetna of CA Government/Medicare	$286.43
Rate for Payer: Cash Price	$262.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$381.90
Rate for Payer: Health Smart Auto/Commercial	$286.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$286.43
Rate for Payer: LLUH Dept of Risk Management WC	$262.56
Rate for Payer: Multiplan Commercial	$358.04

SELEXIPAG 800 MCG TABLET [212418]

Facility

$477.38

Service Code	HCPCS C9399
Hospital Charge Code	901700030
Hospital Revenue Code	259
Min. Negotiated Rate	$262.56
Max. Negotiated Rate	$381.90
Rate for Payer: Cash Price	$262.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$381.90
Rate for Payer: Health Smart Auto/Commercial	$286.43
Rate for Payer: LLUH Dept of Risk Management WC	$262.56
Rate for Payer: Multiplan Commercial	$358.04

SELEXIPAG 800 MCG TABLET [212418]

Facility

$477.38

Service Code	HCPCS C9399
Hospital Charge Code	901700030
Hospital Revenue Code	259
Min. Negotiated Rate	$262.56
Max. Negotiated Rate	$381.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$286.43
Rate for Payer: Aetna of CA Government/Medicare	$286.43
Rate for Payer: Cash Price	$262.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$381.90
Rate for Payer: Health Smart Auto/Commercial	$286.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$286.43
Rate for Payer: LLUH Dept of Risk Management WC	$262.56
Rate for Payer: Multiplan Commercial	$358.04

SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]

Facility

$0.06

Service Code	NDC 0121072208
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

SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP [117388]

Facility

$0.06

Service Code	NDC 0121072208
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

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.07

Service Code	NDC 46122-669-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.19

Service Code	NDC 60687-622-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.34

Service Code	NDC 67618-110-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
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	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
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 Commercial	$0.26

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.03

Service Code	NDC 0536-1248-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.19

Service Code	NDC 60687-622-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.19

Service Code	NDC 60687-622-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.03

Service Code	NDC 57896-455-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.19

Service Code	NDC 60687-622-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.03

Service Code	NDC 57896-455-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]

Facility

$0.19

Service Code	NDC 0904-7440-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

Know your out-of-pocket cost for care.

All Charges