Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$2.13

Service Code	NDC 62756-522-69
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$2.13

Service Code	NDC 62756-522-69
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$1.25

Service Code	NDC 0378-5632-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.00
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.94

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 62756-520-69
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$0.40

Service Code	NDC 65862-146-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 55111-291-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$0.40

Service Code	NDC 65862-146-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 62756-520-69
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 55111-291-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$2.13

Service Code	NDC 62756-521-69
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$0.53

Service Code	NDC 65862-147-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$2.11

Service Code	NDC 63304-098-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.69
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.58

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$0.53

Service Code	NDC 65862-147-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$2.11

Service Code	NDC 63304-098-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.69
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.69
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.58

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$2.13

Service Code	NDC 62756-521-69
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]

Facility

$183.60

Service Code	HCPCS J3030
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$100.98
Max. Negotiated Rate	$146.88
Rate for Payer: Cash Price	$100.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.88
Rate for Payer: Health Smart Auto/Commercial	$110.16
Rate for Payer: LLUH Dept of Risk Management WC	$100.98
Rate for Payer: Multiplan Commercial	$137.70

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]

Facility

$183.60

Service Code	HCPCS J3030
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$100.98
Max. Negotiated Rate	$146.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.16
Rate for Payer: Aetna of CA Government/Medicare	$110.16
Rate for Payer: Cash Price	$100.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$146.88
Rate for Payer: Health Smart Auto/Commercial	$110.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.16
Rate for Payer: LLUH Dept of Risk Management WC	$100.98
Rate for Payer: Multiplan Commercial	$137.70

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]

Facility

$117.60

Service Code	HCPCS J3030
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.68
Max. Negotiated Rate	$94.08
Rate for Payer: Cash Price	$64.68
Rate for Payer: Cash Price	$14.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.12
Rate for Payer: Health Smart Auto/Commercial	$70.56
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: LLUH Dept of Risk Management WC	$64.68
Rate for Payer: Multiplan Commercial	$88.20
Rate for Payer: Multiplan Commercial	$19.80

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]

Facility

$26.40

Service Code	HCPCS J3030
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$21.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.56
Rate for Payer: Aetna of CA Government/Medicare	$15.84
Rate for Payer: Aetna of CA Government/Medicare	$70.56
Rate for Payer: Cash Price	$64.68
Rate for Payer: Cash Price	$14.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.12
Rate for Payer: Health Smart Auto/Commercial	$70.56
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$64.68
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: Multiplan Commercial	$19.80
Rate for Payer: Multiplan Commercial	$88.20

SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]

Facility

$1.26

Service Code	NDC 9994-0803-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.95

SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]

Facility

$1.26

Service Code	NDC 9994-0803-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.01
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.95

SUNITINIB MALATE 12.5 MG CAPSULE [70424]

Facility

$276.70

Service Code	NDC 0069-0550-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$152.19
Max. Negotiated Rate	$221.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$166.02
Rate for Payer: Aetna of CA Government/Medicare	$166.02
Rate for Payer: Cash Price	$152.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$221.36
Rate for Payer: Health Smart Auto/Commercial	$166.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$166.02
Rate for Payer: LLUH Dept of Risk Management WC	$152.19
Rate for Payer: Multiplan Commercial	$207.53

SUNITINIB MALATE 12.5 MG CAPSULE [70424]

Facility

$276.70

Service Code	NDC 0069-0550-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$152.19
Max. Negotiated Rate	$221.36
Rate for Payer: Cash Price	$152.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$221.36
Rate for Payer: Health Smart Auto/Commercial	$166.02
Rate for Payer: LLUH Dept of Risk Management WC	$152.19
Rate for Payer: Multiplan Commercial	$207.53

SUNITINIB MALATE 25 MG CAPSULE [70425]

Facility

$553.41

Service Code	NDC 0069-0770-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$304.38
Max. Negotiated Rate	$442.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$332.05
Rate for Payer: Aetna of CA Government/Medicare	$332.05
Rate for Payer: Cash Price	$304.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$442.73
Rate for Payer: Health Smart Auto/Commercial	$332.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$332.05
Rate for Payer: LLUH Dept of Risk Management WC	$304.38
Rate for Payer: Multiplan Commercial	$415.06

SUNITINIB MALATE 25 MG CAPSULE [70425]

Facility

$553.41

Service Code	NDC 0069-0770-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$304.38
Max. Negotiated Rate	$442.73
Rate for Payer: Cash Price	$304.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$442.73
Rate for Payer: Health Smart Auto/Commercial	$332.05
Rate for Payer: LLUH Dept of Risk Management WC	$304.38
Rate for Payer: Multiplan Commercial	$415.06

Know your out-of-pocket cost for care.

All Charges