Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$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

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 25 MG TABLET [77615]

Facility

$21.89

Service Code	NDC 0006-0221-31
Hospital Charge Code	1711890
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

SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]

Facility

$21.89

Service Code	NDC 0006-0221-31
Hospital Charge Code	1711890
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 50 MG TABLET [77616]

Facility

$21.89

Service Code	NDC 0006-0112-28
Hospital Charge Code	1711891
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

SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]

Facility

$21.89

Service Code	NDC 0006-0112-28
Hospital Charge Code	1711891
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 50 MG TABLET [77616]

Facility

$21.89

Service Code	NDC 0006-0112-31
Hospital Charge Code	1711891
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 50 MG TABLET [77616]

Facility

$21.89

Service Code	NDC 0006-0112-31
Hospital Charge Code	1711891
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

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-04
Hospital Charge Code	NDG7302
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-04
Hospital Charge Code	NDG7302
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-00
Hospital Charge Code	NDG7302
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]

Facility

$0.11

Service Code	NDC 63323-032-00
Hospital Charge Code	NDG7302
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]

Facility

$0.06

Service Code	NDC 9994-0804-43
Hospital Charge Code	1715946
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]

Facility

$0.06

Service Code	NDC 9994-0804-43
Hospital Charge Code	1715946
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION [40917]

Facility

$1,095.86

Service Code	NDC 0187-0010-50
Hospital Charge Code	1759844
Hospital Revenue Code	250
Min. Negotiated Rate	$602.72
Max. Negotiated Rate	$821.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$657.52
Rate for Payer: Aetna of CA Government/Medicare	$657.52
Rate for Payer: Cash Price	$493.14
Rate for Payer: Health Smart Auto/Commercial	$657.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$657.52
Rate for Payer: LLUH Dept of Risk Management WC	$602.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$821.90

SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION [40917]

Facility

$1,095.86

Service Code	NDC 0187-0010-50
Hospital Charge Code	1759844
Hospital Revenue Code	250
Min. Negotiated Rate	$602.72
Max. Negotiated Rate	$876.69
Rate for Payer: Cash Price	$493.14
Rate for Payer: Cigna of CA HMO/PPO	$876.69
Rate for Payer: Health Smart Auto/Commercial	$657.52
Rate for Payer: LLUH Dept of Risk Management WC	$602.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$821.90

SODIUM BENZOATE (BULK) POWDER [7305]

Facility

$0.46

Service Code	NDC 3877905518
Hospital Charge Code	NDG7305
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

SODIUM BENZOATE (BULK) POWDER [7305]

Facility

$0.46

Service Code	NDC 3877905518
Hospital Charge Code	NDG7305
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

SODIUM BENZOATE ORAL SUSPENSION COMPOUND 100 MG/ML [4080336]

Facility

$0.02

Service Code	NDC 9994-0803-36
Hospital Charge Code	1715216
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
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	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

SODIUM BENZOATE ORAL SUSPENSION COMPOUND 100 MG/ML [4080336]

Facility

$0.02

Service Code	NDC 9994-0803-36
Hospital Charge Code	1715216
Hospital Revenue Code	259
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: 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 Beech St/Commercial/PHCS	$0.02

SODIUM BICARB 8.4% (1 MEQ/ML) IV WRAP (SYRINGE/VIAL) [4087309]

Facility

$0.21

Service Code	NDC 51754-5001-4
Hospital Charge Code	1720286
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARB 8.4% (1 MEQ/ML) IV WRAP (SYRINGE/VIAL) [4087309]

Facility

$0.39

Service Code	NDC 76329-3352-1
Hospital Charge Code	1720026
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

SODIUM BICARB 8.4% (1 MEQ/ML) IV WRAP (SYRINGE/VIAL) [4087309]

Facility

$0.39

Service Code	NDC 76329-3352-1
Hospital Charge Code	1720026
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

SODIUM BICARB 8.4% (1 MEQ/ML) IV WRAP (SYRINGE/VIAL) [4087309]

Facility

$0.52

Service Code	NDC 63323-089-50
Hospital Charge Code	1720286
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

SODIUM BICARB 8.4% (1 MEQ/ML) IV WRAP (SYRINGE/VIAL) [4087309]

Facility

$0.21

Service Code	NDC 51754-5001-1
Hospital Charge Code	1720286
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

Know your out-of-pocket cost for care.

All Charges