Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$13.20

Service Code	NDC 0006-0277-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$13.20

Service Code	NDC 0006-0277-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$13.20

Service Code	NDC 0006-0277-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$13.20

Service Code	NDC 0006-0277-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

$13.20

Service Code	NDC 0006-0221-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

$13.20

Service Code	NDC 0006-0221-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$13.20

Service Code	NDC 0006-0112-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$13.20

Service Code	NDC 0006-0112-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$13.20

Service Code	NDC 0006-0112-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$13.20

Service Code	NDC 0006-0112-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]

Facility

$0.67

Service Code	NDC 0409-7299-73
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]

Facility

$0.30

Service Code	NDC 69784-231-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]

Facility

$0.67

Service Code	NDC 0409-7299-73
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]

Facility

$0.30

Service Code	NDC 69784-231-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]

Facility

$0.06

Service Code	NDC 9994-0804-43
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

SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]

Facility

$0.06

Service Code	NDC 9994-0804-43
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

SODIUM BENZOATE (BULK) POWDER [7305]

Facility

$0.46

Service Code	NDC 3877905518
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

SODIUM BENZOATE (BULK) POWDER [7305]

Facility

$0.46

Service Code	NDC 3877905518
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

SODIUM BENZOATE ORAL SUSPENSION COMPOUND 100 MG/ML [4080336]

Facility

$0.02

Service Code	NDC 9994-0803-36
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

SODIUM BENZOATE ORAL SUSPENSION COMPOUND 100 MG/ML [4080336]

Facility

$0.02

Service Code	NDC 9994-0803-36
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

SODIUM BICARB 8.4% (1 MEQ/ML) IV WRAP (SYRINGE/VIAL) [4087309]

Facility

$0.21

Service Code	HCPCS J3490
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.16

Know your out-of-pocket cost for care.

All Charges