Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.04

Service Code	NDC 49348-188-10
Hospital Charge Code	1711183
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: 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 Beech St/Commercial/PHCS	$0.03

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.04

Service Code	NDC 24385-118-78
Hospital Charge Code	1711183
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.03

Service Code	NDC 57896-791-01
Hospital Charge Code	1711183
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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 Beech St/Commercial/PHCS	$0.02

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.03

Service Code	NDC 57896-791-01
Hospital Charge Code	1711183
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

SIMETHICONE 80 MG CHEWABLE TABLET [7227]

Facility

$0.03

Service Code	NDC 8770170344
Hospital Charge Code	1711183
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 395266116
Hospital Charge Code	ERX7242
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 3172293747
Hospital Charge Code	ERX7242
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 3172293747
Hospital Charge Code	ERX7242
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: 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 Beech St/Commercial/PHCS	$0.03

SIMPLE SYRUP [7242]

Facility

$0.04

Service Code	NDC 395266116
Hospital Charge Code	ERX7242
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: 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 Beech St/Commercial/PHCS	$0.03

SIMVASTATIN 20 MG TABLET [11365]

Facility

$0.29

Service Code	NDC 68084-512-01
Hospital Charge Code	1711607
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.22

SIMVASTATIN 20 MG TABLET [11365]

Facility

$0.29

Service Code	NDC 68084-512-01
Hospital Charge Code	1711607
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.22

SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]

Facility

$152.00

Service Code	CPT J2805
Hospital Charge Code	ERX11368
Hospital Revenue Code	636
Min. Negotiated Rate	$83.60
Max. Negotiated Rate	$121.60
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna of CA HMO/PPO	$121.60
Rate for Payer: Health Smart Auto/Commercial	$91.20
Rate for Payer: LLUH Dept of Risk Management WC	$83.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.00

SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]

Facility

$152.00

Service Code	CPT J2805
Hospital Charge Code	ERX11368
Hospital Revenue Code	636
Min. Negotiated Rate	$83.60
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$91.20
Rate for Payer: Aetna of CA Government/Medicare	$91.20
Rate for Payer: Cash Price	$68.40
Rate for Payer: Health Smart Auto/Commercial	$91.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$91.20
Rate for Payer: LLUH Dept of Risk Management WC	$83.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$114.00

SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]

Facility

$300.49

Service Code	CPT Q2043
Hospital Charge Code	1753491
Hospital Revenue Code	636
Min. Negotiated Rate	$165.27
Max. Negotiated Rate	$240.39
Rate for Payer: Cash Price	$135.22
Rate for Payer: Cigna of CA HMO/PPO	$240.39
Rate for Payer: Health Smart Auto/Commercial	$180.29
Rate for Payer: LLUH Dept of Risk Management WC	$165.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$225.37

SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION [104852]

Facility

$300.49

Service Code	CPT Q2043
Hospital Charge Code	1753491
Hospital Revenue Code	636
Min. Negotiated Rate	$165.27
Max. Negotiated Rate	$225.37
Rate for Payer: Health Smart Auto/Commercial	$180.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$180.29
Rate for Payer: Aetna of CA Government/Medicare	$180.29
Rate for Payer: Cash Price	$135.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$180.29
Rate for Payer: LLUH Dept of Risk Management WC	$165.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$225.37

SIROLIMUS 0.5 MG TABLET [104764]

Facility

$10.35

Service Code	CPT J7520
Hospital Charge Code	1712518
Hospital Revenue Code	636
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$7.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.93
Rate for Payer: Aetna of CA Government/Medicare	$6.21
Rate for Payer: Aetna of CA Government/Medicare	$12.38
Rate for Payer: Aetna of CA Government/Medicare	$3.93
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cash Price	$2.95
Rate for Payer: Cash Price	$9.28
Rate for Payer: Health Smart Auto/Commercial	$12.38
Rate for Payer: Health Smart Auto/Commercial	$3.93
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.21
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: LLUH Dept of Risk Management WC	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.91

SIROLIMUS 0.5 MG TABLET [104764]

Facility

$20.63

Service Code	CPT J7520
Hospital Charge Code	1712518
Hospital Revenue Code	636
Min. Negotiated Rate	$11.35
Max. Negotiated Rate	$16.50
Rate for Payer: Cash Price	$9.28
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cash Price	$2.95
Rate for Payer: Cigna of CA HMO/PPO	$8.28
Rate for Payer: Cigna of CA HMO/PPO	$16.50
Rate for Payer: Cigna of CA HMO/PPO	$5.24
Rate for Payer: Health Smart Auto/Commercial	$12.38
Rate for Payer: Health Smart Auto/Commercial	$3.93
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: LLUH Dept of Risk Management WC	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.35
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.76

SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]

Facility

$17.50

Service Code	CPT J7520
Hospital Charge Code	1715200
Hospital Revenue Code	636
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$7.88
Rate for Payer: Cash Price	$9.47
Rate for Payer: Cigna of CA HMO/PPO	$14.00
Rate for Payer: Cigna of CA HMO/PPO	$16.84
Rate for Payer: Health Smart Auto/Commercial	$12.63
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$11.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.12

SIROLIMUS 1 MG/ML ORAL SOLUTION [26336]

Facility

$17.50

Service Code	CPT J7520
Hospital Charge Code	1715200
Hospital Revenue Code	636
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$13.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.63
Rate for Payer: Aetna of CA Government/Medicare	$10.50
Rate for Payer: Aetna of CA Government/Medicare	$12.63
Rate for Payer: Cash Price	$9.47
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: Health Smart Auto/Commercial	$12.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.63
Rate for Payer: LLUH Dept of Risk Management WC	$11.58
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.79

SIROLIMUS 1 MG TABLET [28958]

Facility

$16.66

Service Code	CPT J7520
Hospital Charge Code	1711808
Hospital Revenue Code	636
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$13.33
Rate for Payer: Cash Price	$7.50
Rate for Payer: Cash Price	$4.05
Rate for Payer: Cigna of CA HMO/PPO	$13.33
Rate for Payer: Cigna of CA HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$10.00
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: LLUH Dept of Risk Management WC	$9.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.75

SIROLIMUS 1 MG TABLET [28958]

Facility

$9.00

Service Code	CPT J7520
Hospital Charge Code	1711808
Hospital Revenue Code	636
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$6.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.00
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$10.00
Rate for Payer: Cash Price	$4.05
Rate for Payer: Cash Price	$7.50
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Health Smart Auto/Commercial	$10.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: LLUH Dept of Risk Management WC	$9.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.75

SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]

Facility

$8,512.06

Service Code	NDC 80803-153-50
Hospital Charge Code	ERX233123
Hospital Revenue Code	636
Min. Negotiated Rate	$4,681.63
Max. Negotiated Rate	$6,384.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,107.24
Rate for Payer: Aetna of CA Government/Medicare	$5,107.24
Rate for Payer: Cash Price	$3,830.43
Rate for Payer: Health Smart Auto/Commercial	$5,107.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,107.24
Rate for Payer: LLUH Dept of Risk Management WC	$4,681.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,384.04

SIROLIMUS-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION [233123]

Facility

$8,512.06

Service Code	NDC 80803-153-50
Hospital Charge Code	ERX233123
Hospital Revenue Code	636
Min. Negotiated Rate	$4,681.63
Max. Negotiated Rate	$6,809.65
Rate for Payer: Cash Price	$3,830.43
Rate for Payer: Cigna of CA HMO/PPO	$6,809.65
Rate for Payer: Health Smart Auto/Commercial	$5,107.24
Rate for Payer: LLUH Dept of Risk Management WC	$4,681.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,384.04

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$21.89

Service Code	NDC 0006-0277-01
Hospital Charge Code	1711892
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$16.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.13
Rate for Payer: Aetna of CA Government/Medicare	$13.13
Rate for Payer: Cash Price	$9.85
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.42

SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]

Facility

$21.89

Service Code	NDC 0006-0277-31
Hospital Charge Code	1711892
Hospital Revenue Code	259
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$17.51
Rate for Payer: Cash Price	$9.85
Rate for Payer: Cigna of CA HMO/PPO	$17.51
Rate for Payer: Health Smart Auto/Commercial	$13.13
Rate for Payer: LLUH Dept of Risk Management WC	$12.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.42

Know your out-of-pocket cost for care.

All Charges