Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]

Facility

$46.20

Service Code	NDC 24201-201-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$25.41
Max. Negotiated Rate	$36.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.72
Rate for Payer: Aetna of CA Government/Medicare	$27.72
Rate for Payer: Cash Price	$25.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.96
Rate for Payer: Health Smart Auto/Commercial	$27.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$25.41
Rate for Payer: Multiplan Commercial	$34.65

SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]

Facility

$46.88

Service Code	NDC 67457-163-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$25.78
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.13
Rate for Payer: Aetna of CA Government/Medicare	$28.13
Rate for Payer: Cash Price	$25.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.50
Rate for Payer: Health Smart Auto/Commercial	$28.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.13
Rate for Payer: LLUH Dept of Risk Management WC	$25.78
Rate for Payer: Multiplan Commercial	$35.16

SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]

Facility

$46.20

Service Code	NDC 24201-201-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$25.41
Max. Negotiated Rate	$36.96
Rate for Payer: Cash Price	$25.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.96
Rate for Payer: Health Smart Auto/Commercial	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$25.41
Rate for Payer: Multiplan Commercial	$34.65

SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]

Facility

$2.40

Service Code	HCPCS J0209
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]

Facility

$2.40

Service Code	HCPCS J0209
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]

Facility

$34.46

Service Code	NDC 0310-1110-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]

Facility

$34.46

Service Code	NDC 0310-1110-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]

Facility

$34.46

Service Code	NDC 0310-1110-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.68
Rate for Payer: Aetna of CA Government/Medicare	$20.68
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]

Facility

$34.46

Service Code	NDC 0310-1110-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.68
Rate for Payer: Aetna of CA Government/Medicare	$20.68
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]

Facility

$34.46

Service Code	NDC 0310-1105-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.68
Rate for Payer: Aetna of CA Government/Medicare	$20.68
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]

Facility

$34.46

Service Code	NDC 0310-1105-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]

Facility

$34.46

Service Code	NDC 0310-1105-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.68
Rate for Payer: Aetna of CA Government/Medicare	$20.68
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]

Facility

$34.46

Service Code	NDC 0310-1105-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]

Facility

$34.46

Service Code	NDC 0310-1105-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.68
Rate for Payer: Aetna of CA Government/Medicare	$20.68
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]

Facility

$34.46

Service Code	NDC 0310-1105-39
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$27.57
Rate for Payer: Cash Price	$18.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.57
Rate for Payer: Health Smart Auto/Commercial	$20.68
Rate for Payer: LLUH Dept of Risk Management WC	$18.95
Rate for Payer: Multiplan Commercial	$25.84

SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]

Facility

$1.16

Service Code	NDC 46287-006-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]

Facility

$1.16

Service Code	NDC 46287-006-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]

Facility

$0.49

Service Code	NDC 1011905220
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]

Facility

$0.49

Service Code	NDC 1011905220
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

SOLIFENACIN 5 MG TABLET [40392]

Facility

$0.48

Service Code	NDC 67877-527-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
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	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

SOLIFENACIN 5 MG TABLET [40392]

Facility

$0.83

Service Code	NDC 60505-4702-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.62

SOLIFENACIN 5 MG TABLET [40392]

Facility

$0.48

Service Code	NDC 67877-527-30
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	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

SOLIFENACIN 5 MG TABLET [40392]

Facility

$0.83

Service Code	NDC 60505-4702-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.62

SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]

Facility

$676.56

Service Code	HCPCS J2941
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$372.11
Max. Negotiated Rate	$541.25
Rate for Payer: Cash Price	$372.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$541.25
Rate for Payer: Health Smart Auto/Commercial	$405.94
Rate for Payer: LLUH Dept of Risk Management WC	$372.11
Rate for Payer: Multiplan Commercial	$507.42

SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]

Facility

$676.56

Service Code	HCPCS J2941
Hospital Charge Code	901700033
Hospital Revenue Code	636
Min. Negotiated Rate	$372.11
Max. Negotiated Rate	$541.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$405.94
Rate for Payer: Aetna of CA Government/Medicare	$405.94
Rate for Payer: Cash Price	$372.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$541.25
Rate for Payer: Health Smart Auto/Commercial	$405.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$405.94
Rate for Payer: LLUH Dept of Risk Management WC	$372.11
Rate for Payer: Multiplan Commercial	$507.42

Know your out-of-pocket cost for care.

All Charges