Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$2.85

Service Code	NDC 0517-2505-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.71
Rate for Payer: Aetna of CA Government/Medicare	$1.71
Rate for Payer: Cash Price	$1.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.28
Rate for Payer: Health Smart Auto/Commercial	$1.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.71
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Commercial	$2.14

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$1.18

Service Code	NDC 0409-7295-11
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$2.85

Service Code	NDC 0517-2505-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.28
Rate for Payer: Cash Price	$1.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.28
Rate for Payer: Health Smart Auto/Commercial	$1.71
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Commercial	$2.14

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$3.52

Service Code	NDC 70069-747-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$2.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.11
Rate for Payer: Aetna of CA Government/Medicare	$2.11
Rate for Payer: Cash Price	$1.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.82
Rate for Payer: Health Smart Auto/Commercial	$2.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.94
Rate for Payer: Multiplan Commercial	$2.64

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$5.76

Service Code	NDC 65219-052-29
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$4.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.46
Rate for Payer: Aetna of CA Government/Medicare	$3.46
Rate for Payer: Cash Price	$3.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.61
Rate for Payer: Health Smart Auto/Commercial	$3.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.46
Rate for Payer: LLUH Dept of Risk Management WC	$3.17
Rate for Payer: Multiplan Commercial	$4.32

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$3.84

Service Code	NDC 65219-054-09
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Cash Price	$2.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.88

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$2.85

Service Code	NDC 65219-056-09
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.71
Rate for Payer: Aetna of CA Government/Medicare	$1.71
Rate for Payer: Cash Price	$1.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.28
Rate for Payer: Health Smart Auto/Commercial	$1.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.71
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Commercial	$2.14

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$5.76

Service Code	NDC 65219-052-09
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$4.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.46
Rate for Payer: Aetna of CA Government/Medicare	$3.46
Rate for Payer: Cash Price	$3.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.61
Rate for Payer: Health Smart Auto/Commercial	$3.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.46
Rate for Payer: LLUH Dept of Risk Management WC	$3.17
Rate for Payer: Multiplan Commercial	$4.32

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$2.85

Service Code	NDC 65219-056-29
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.71
Rate for Payer: Aetna of CA Government/Medicare	$1.71
Rate for Payer: Cash Price	$1.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.28
Rate for Payer: Health Smart Auto/Commercial	$1.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.71
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Commercial	$2.14

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$5.76

Service Code	NDC 65219-052-09
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$4.61
Rate for Payer: Cash Price	$3.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.61
Rate for Payer: Health Smart Auto/Commercial	$3.46
Rate for Payer: LLUH Dept of Risk Management WC	$3.17
Rate for Payer: Multiplan Commercial	$4.32

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$1.18

Service Code	NDC 0409-7295-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$1.18

Service Code	NDC 0409-7295-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Commercial	$0.89

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$3.84

Service Code	NDC 65219-054-29
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.07
Rate for Payer: Cash Price	$2.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.88

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]

Facility

$3.84

Service Code	NDC 65219-054-29
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.30
Rate for Payer: Aetna of CA Government/Medicare	$2.30
Rate for Payer: Cash Price	$2.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.88

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

$0.65

Service Code	NDC 6025800615
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

$0.65

Service Code	NDC 6025800601
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

$0.65

Service Code	NDC 6025800601
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

$0.44

Service Code	NDC 8068117200
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

$0.65

Service Code	NDC 6025800615
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

$0.44

Service Code	NDC 8068117200
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]

Facility

$0.08

Service Code	NDC 0536-1271-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
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	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]

Facility

$0.08

Service Code	NDC 0536-1271-80
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	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]

Facility

$0.02

Service Code	NDC 0395-2325-16
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

POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]

Facility

$0.02

Service Code	NDC 0395-2325-16
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

POVIDONE-IODINE 5 % EYE SOLUTION [19791]

Facility

$0.71

Service Code	NDC 0065-0411-30
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

Know your out-of-pocket cost for care.

All Charges