Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]

Facility

$407.80

Service Code	NDC 8065183055
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$224.29
Max. Negotiated Rate	$326.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$244.68
Rate for Payer: Aetna of CA Government/Medicare	$244.68
Rate for Payer: Cash Price	$224.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$326.24
Rate for Payer: Health Smart Auto/Commercial	$244.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$244.68
Rate for Payer: LLUH Dept of Risk Management WC	$224.29
Rate for Payer: Multiplan Commercial	$305.85

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]

Facility

$84.59

Service Code	NDC 8544-5085-81
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$46.52
Max. Negotiated Rate	$67.67
Rate for Payer: Cash Price	$46.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.67
Rate for Payer: Health Smart Auto/Commercial	$50.75
Rate for Payer: LLUH Dept of Risk Management WC	$46.52
Rate for Payer: Multiplan Commercial	$63.44

SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]

Facility

$261.36

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$143.75
Max. Negotiated Rate	$209.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$156.82
Rate for Payer: Aetna of CA Government/Medicare	$156.82
Rate for Payer: Cash Price	$143.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$209.09
Rate for Payer: Health Smart Auto/Commercial	$156.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$156.82
Rate for Payer: LLUH Dept of Risk Management WC	$143.75
Rate for Payer: Multiplan Commercial	$196.02

SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]

Facility

$261.36

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$143.75
Max. Negotiated Rate	$209.09
Rate for Payer: Cash Price	$143.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$209.09
Rate for Payer: Health Smart Auto/Commercial	$156.82
Rate for Payer: LLUH Dept of Risk Management WC	$143.75
Rate for Payer: Multiplan Commercial	$196.02

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]

Facility

$232.00

Service Code	HCPCS J3490
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Cash Price	$127.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Commercial	$174.00

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]

Facility

$232.00

Service Code	HCPCS J3490
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.20
Rate for Payer: Aetna of CA Government/Medicare	$139.20
Rate for Payer: Cash Price	$127.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Commercial	$174.00

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]

Facility

$232.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Cash Price	$127.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Commercial	$174.00

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]

Facility

$232.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.20
Rate for Payer: Aetna of CA Government/Medicare	$139.20
Rate for Payer: Cash Price	$127.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Commercial	$174.00

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.04

Service Code	NDC 0436-0672-16
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

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.04

Service Code	NDC 0436-0672-16
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

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.04

Service Code	NDC 3932806412
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

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.04

Service Code	NDC 3932806412
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

SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.04

Service Code	NDC 0436-0936-16
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

SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.04

Service Code	NDC 39328-063-25
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

SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.04

Service Code	NDC 39328-063-25
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

SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.04

Service Code	NDC 0436-0936-16
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.04

Service Code	NDC 0436-0946-16
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.04

Service Code	NDC 0436-0946-16
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.04

Service Code	NDC 39328-062-50
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.04

Service Code	NDC 39328-062-50
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

SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]

Facility

$1.20

Service Code	NDC 63323-019-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]

Facility

$1.20

Service Code	NDC 63323-019-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]

Facility

$442.90

Service Code	HCPCS A9516
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$243.59
Max. Negotiated Rate	$354.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$265.74
Rate for Payer: Aetna of CA Government/Medicare	$265.74
Rate for Payer: Cash Price	$243.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$354.32
Rate for Payer: Health Smart Auto/Commercial	$265.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$265.74
Rate for Payer: LLUH Dept of Risk Management WC	$243.59
Rate for Payer: Multiplan Commercial	$332.18

SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]

Facility

$442.90

Service Code	HCPCS A9516
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$243.59
Max. Negotiated Rate	$354.32
Rate for Payer: Cash Price	$243.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$354.32
Rate for Payer: Health Smart Auto/Commercial	$265.74
Rate for Payer: LLUH Dept of Risk Management WC	$243.59
Rate for Payer: Multiplan Commercial	$332.18

SODIUM IODIDE-131 (I-131) 500 MCI/0.5 ML ORAL KIT [211669]

Facility

$15.53

Service Code	HCPCS A9530
Hospital Charge Code	901700056
Hospital Revenue Code	344
Min. Negotiated Rate	$8.54
Max. Negotiated Rate	$12.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.32
Rate for Payer: Aetna of CA Government/Medicare	$9.32
Rate for Payer: Cash Price	$8.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.42
Rate for Payer: Health Smart Auto/Commercial	$9.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$8.54
Rate for Payer: Multiplan Commercial	$11.65

Know your out-of-pocket cost for care.

All Charges