Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.02

Service Code	NDC 0264-7850-20
Hospital Charge Code	901700008
Hospital Revenue Code	258
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

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.17

Service Code	HCPCS A4216
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22
Rate for Payer: Multiplan Commercial	$0.29
Rate for Payer: Multiplan Commercial	$0.31
Rate for Payer: Multiplan Commercial	$0.13

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.41

Service Code	HCPCS A4216
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.31
Rate for Payer: Multiplan Commercial	$0.13
Rate for Payer: Multiplan Commercial	$0.22
Rate for Payer: Multiplan Commercial	$0.29

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.02

Service Code	NDC 0264-7850-20
Hospital Charge Code	901700008
Hospital Revenue Code	258
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

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.01

Service Code	NDC 0264-7850-10
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.01

Service Code	NDC 0264-7850-10
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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	$0.01
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	$0.01

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.25

Service Code	NDC 0409-3977-03
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.25

Service Code	NDC 0409-3977-03
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

STERILE WATER FOR INJECTION. [4081186]

Facility

$0.01

Service Code	NDC 0264-7850-00
Hospital Charge Code	901700008
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION [7508]

Facility

$90.00

Service Code	HCPCS J3000
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION [7508]

Facility

$90.00

Service Code	HCPCS J3000
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

SUCCIMER 100 MG CAPSULE [11438]

Facility

$26.44

Service Code	NDC 55292-201-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$21.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.86
Rate for Payer: Aetna of CA Government/Medicare	$15.86
Rate for Payer: Cash Price	$14.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.15
Rate for Payer: Health Smart Auto/Commercial	$15.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.86
Rate for Payer: LLUH Dept of Risk Management WC	$14.54
Rate for Payer: Multiplan Commercial	$19.83

SUCCIMER 100 MG CAPSULE [11438]

Facility

$26.44

Service Code	NDC 55292-201-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$21.15
Rate for Payer: Cash Price	$14.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.15
Rate for Payer: Health Smart Auto/Commercial	$15.86
Rate for Payer: LLUH Dept of Risk Management WC	$14.54
Rate for Payer: Multiplan Commercial	$19.83

SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE [121307]

Facility

$5.15

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.18
Rate for Payer: Aetna of CA Government/Medicare	$2.18
Rate for Payer: Aetna of CA Government/Medicare	$3.09
Rate for Payer: Cash Price	$1.99
Rate for Payer: Cash Price	$2.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.90
Rate for Payer: Health Smart Auto/Commercial	$3.09
Rate for Payer: Health Smart Auto/Commercial	$2.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.09
Rate for Payer: LLUH Dept of Risk Management WC	$2.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.83
Rate for Payer: Multiplan Commercial	$3.86
Rate for Payer: Multiplan Commercial	$2.72

SUCCINYLCHOLINE CHLORIDE 100 MG/5 ML (20 MG/ML) INTRAVENOUS SYRINGE [121307]

Facility

$3.63

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.90
Rate for Payer: Cash Price	$1.99
Rate for Payer: Cash Price	$2.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.90
Rate for Payer: Health Smart Auto/Commercial	$2.18
Rate for Payer: Health Smart Auto/Commercial	$3.09
Rate for Payer: LLUH Dept of Risk Management WC	$2.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.83
Rate for Payer: Multiplan Commercial	$2.72
Rate for Payer: Multiplan Commercial	$3.86

SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML INJECTION VIAL - CODE [4087536]

Facility

$2.33

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Commercial	$1.75

SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML INJECTION VIAL - CODE [4087536]

Facility

$2.33

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Commercial	$1.75

SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]

Facility

$1.02

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]

Facility

$1.02

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS INJECTION. [408216150]

Facility

$1.20

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$1.49

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS INJECTION. [408216150]

Facility

$1.20

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$1.49

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS SYRINGE [216150]

Facility

$4.55

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.64
Rate for Payer: Cash Price	$2.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.64
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Commercial	$3.41

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS SYRINGE [216150]

Facility

$4.55

Service Code	HCPCS J0330
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.73
Rate for Payer: Aetna of CA Government/Medicare	$2.73
Rate for Payer: Cash Price	$2.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.64
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.73
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Commercial	$3.41

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.08

Service Code	NDC 68094-043-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.81

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.10

Service Code	NDC 60687-738-42
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.66
Rate for Payer: Aetna of CA Government/Medicare	$0.66
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.88
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Commercial	$0.83

Know your out-of-pocket cost for care.

All Charges