Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.05

Service Code	NDC 24385-118-78
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

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.03

Service Code	NDC 57896-791-01
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

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.18

Service Code	NDC 57896-791-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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

SIMPLE SYRUP [7242]

Facility

$0.58

Service Code	NDC 3877917798
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

SIMPLE SYRUP [7242]

Facility

$0.58

Service Code	NDC 3877917791
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 0395266116
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.03
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	$0.03

SIMPLE SYRUP [7242]

Facility

$0.58

Service Code	NDC 3877917791
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 0395266116
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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	$0.03

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 3172293747
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.03
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	$0.03

SIMPLE SYRUP [7242]

Facility

$0.58

Service Code	NDC 3877917798
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 3172293747
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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	$0.03

SIMVASTATIN 20 MG TABLET [11365]

Facility

$0.29

Service Code	NDC 68084-512-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
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	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
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	$0.16
Rate for Payer: Multiplan Commercial	$0.22

SIMVASTATIN 20 MG TABLET [11365]

Facility

$0.29

Service Code	NDC 68084-512-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]

Facility

$156.56

Service Code	HCPCS J2805
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$86.11
Max. Negotiated Rate	$125.25
Rate for Payer: Cash Price	$86.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.25
Rate for Payer: Health Smart Auto/Commercial	$93.94
Rate for Payer: LLUH Dept of Risk Management WC	$86.11
Rate for Payer: Multiplan Commercial	$117.42

SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]

Facility

$156.56

Service Code	HCPCS J2805
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$86.11
Max. Negotiated Rate	$125.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$93.94
Rate for Payer: Aetna of CA Government/Medicare	$93.94
Rate for Payer: Cash Price	$86.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.25
Rate for Payer: Health Smart Auto/Commercial	$93.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$93.94
Rate for Payer: LLUH Dept of Risk Management WC	$86.11
Rate for Payer: Multiplan Commercial	$117.42

SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]

Facility

$300.49

Service Code	HCPCS Q2043
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$165.27
Max. Negotiated Rate	$240.39
Rate for Payer: Cash Price	$165.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$240.39
Rate for Payer: Health Smart Auto/Commercial	$180.29
Rate for Payer: LLUH Dept of Risk Management WC	$165.27
Rate for Payer: Multiplan Commercial	$225.37

SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]

Facility

$300.49

Service Code	HCPCS Q2043
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$165.27
Max. Negotiated Rate	$240.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$180.29
Rate for Payer: Aetna of CA Government/Medicare	$180.29
Rate for Payer: Cash Price	$165.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$240.39
Rate for Payer: Health Smart Auto/Commercial	$180.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$180.29
Rate for Payer: LLUH Dept of Risk Management WC	$165.27
Rate for Payer: Multiplan Commercial	$225.37

SIROLIMUS 0.5 MG TABLET [104764]

Facility

$6.55

Service Code	HCPCS J7520
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$5.24
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$5.69
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.28
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$3.93
Rate for Payer: LLUH Dept of Risk Management WC	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$7.76
Rate for Payer: Multiplan Commercial	$3.60
Rate for Payer: Multiplan Commercial	$4.91

SIROLIMUS 0.5 MG TABLET [104764]

Facility

$6.55

Service Code	HCPCS J7520
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$5.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$6.21
Rate for Payer: Aetna of CA Government/Medicare	$3.93
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$5.69
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$3.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.93
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: LLUH Dept of Risk Management WC	$3.60
Rate for Payer: Multiplan Commercial	$7.76
Rate for Payer: Multiplan Commercial	$3.60
Rate for Payer: Multiplan Commercial	$4.91

SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]

Facility

$21.05

Service Code	HCPCS J7520
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.58
Max. Negotiated Rate	$16.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.22
Rate for Payer: Aetna of CA Government/Medicare	$12.63
Rate for Payer: Aetna of CA Government/Medicare	$7.22
Rate for Payer: Cash Price	$11.58
Rate for Payer: Cash Price	$6.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.63
Rate for Payer: Health Smart Auto/Commercial	$7.22
Rate for Payer: Health Smart Auto/Commercial	$12.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.63
Rate for Payer: LLUH Dept of Risk Management WC	$11.58
Rate for Payer: LLUH Dept of Risk Management WC	$6.62
Rate for Payer: Multiplan Commercial	$15.79
Rate for Payer: Multiplan Commercial	$9.03

SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]

Facility

$21.05

Service Code	HCPCS J7520
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$11.58
Max. Negotiated Rate	$16.84
Rate for Payer: Cash Price	$11.58
Rate for Payer: Cash Price	$6.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.84
Rate for Payer: Health Smart Auto/Commercial	$7.22
Rate for Payer: Health Smart Auto/Commercial	$12.63
Rate for Payer: LLUH Dept of Risk Management WC	$11.58
Rate for Payer: LLUH Dept of Risk Management WC	$6.62
Rate for Payer: Multiplan Commercial	$9.03
Rate for Payer: Multiplan Commercial	$15.79

SIROLIMUS 1 MG TABLET [28958]

Facility

$16.66

Service Code	HCPCS J7520
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$13.33
Rate for Payer: Cash Price	$9.16
Rate for Payer: Cash Price	$2.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.33
Rate for Payer: Health Smart Auto/Commercial	$10.00
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$9.16
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Commercial	$4.05
Rate for Payer: Multiplan Commercial	$12.49

SIROLIMUS 1 MG TABLET [28958]

Facility

$16.66

Service Code	HCPCS J7520
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$13.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.24
Rate for Payer: Aetna of CA Government/Medicare	$3.24
Rate for Payer: Aetna of CA Government/Medicare	$10.00
Rate for Payer: Cash Price	$2.97
Rate for Payer: Cash Price	$9.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.32
Rate for Payer: Health Smart Auto/Commercial	$10.00
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.00
Rate for Payer: LLUH Dept of Risk Management WC	$9.16
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Commercial	$12.49
Rate for Payer: Multiplan Commercial	$4.05

SITAGLIPTIN 100 MG TABLET [240314]

Facility

$3.20

Service Code	NDC 70710-1901-3
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.92
Rate for Payer: Aetna of CA Government/Medicare	$1.92
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.56
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Commercial	$2.40

SITAGLIPTIN 100 MG TABLET [240314]

Facility

$3.20

Service Code	NDC 70710-1901-3
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$2.56
Rate for Payer: Cash Price	$1.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.56
Rate for Payer: Health Smart Auto/Commercial	$1.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.76
Rate for Payer: Multiplan Commercial	$2.40

Know your out-of-pocket cost for care.

All Charges