Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]

Facility

$38.12

Service Code	NDC 0085-4331-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$20.97
Max. Negotiated Rate	$30.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.87
Rate for Payer: Aetna of CA Government/Medicare	$22.87
Rate for Payer: Cash Price	$20.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.50
Rate for Payer: Health Smart Auto/Commercial	$22.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.87
Rate for Payer: LLUH Dept of Risk Management WC	$20.97
Rate for Payer: Multiplan Commercial	$28.59

POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]

Facility

$19.40

Service Code	NDC 68462-904-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$10.67
Max. Negotiated Rate	$15.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.64
Rate for Payer: Aetna of CA Government/Medicare	$11.64
Rate for Payer: Cash Price	$10.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.52
Rate for Payer: Health Smart Auto/Commercial	$11.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.64
Rate for Payer: LLUH Dept of Risk Management WC	$10.67
Rate for Payer: Multiplan Commercial	$14.55

POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION [205239]

Facility

$19.40

Service Code	NDC 68462-904-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$10.67
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$10.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.52
Rate for Payer: Health Smart Auto/Commercial	$11.64
Rate for Payer: LLUH Dept of Risk Management WC	$10.67
Rate for Payer: Multiplan Commercial	$14.55

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.27

Service Code	NDC 0409-3294-51
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.32

Service Code	NDC 51754-2001-4
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.26

Service Code	NDC 51754-2004-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.32

Service Code	NDC 0409-8183-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
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	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
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	$0.18
Rate for Payer: Multiplan Commercial	$0.24

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.32

Service Code	NDC 0409-8183-11
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
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	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
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	$0.18
Rate for Payer: Multiplan Commercial	$0.24

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.26

Service Code	NDC 51754-2004-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.32

Service Code	NDC 0409-8183-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.27

Service Code	NDC 0409-3294-61
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.27

Service Code	NDC 0409-3294-61
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.27

Service Code	NDC 0409-3294-51
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.32

Service Code	NDC 51754-2001-4
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
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	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
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	$0.18
Rate for Payer: Multiplan Commercial	$0.24

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [6420]

Facility

$0.32

Service Code	NDC 0409-8183-11
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

POTASSIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080437]

Facility

$0.03

Service Code	NDC 9994-0804-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

POTASSIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080437]

Facility

$0.03

Service Code	NDC 9994-0804-37
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

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.47

Service Code	NDC 9999-6432-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.28

Service Code	NDC 81033-412-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.28

Service Code	NDC 81033-412-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.47

Service Code	NDC 9999-6432-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.07

Service Code	NDC 0121-0948-16
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

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.28

Service Code	NDC 81033-412-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.15

Service Code	NDC 69238-1459-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.11

POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID [6432]

Facility

$0.28

Service Code	NDC 81033-220-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

Know your out-of-pocket cost for care.

All Charges