Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$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

$0.52

Service Code	NDC 63323-089-50
Hospital Charge Code	1720286
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [111015]

Facility

$0.21

Service Code	CPT J3490
Hospital Charge Code	1720286
Hospital Revenue Code	636
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 BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [111015]

Facility

$0.21

Service Code	CPT J3490
Hospital Charge Code	1720286
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) [400328]

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 BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) [400328]

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	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) [400328]

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	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) [400328]

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

SODIUM BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) - UH [40803009]

Facility

$0.21

Service Code	NDC 9994-3000-04
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) - UH [40803009]

Facility

$0.21

Service Code	NDC 9994-3000-03
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) - UH [40803009]

Facility

$0.21

Service Code	NDC 9994-3000-04
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 BICARBONATE 1 MEQ/ML INFUSION (UNDILUTED) - UH [40803009]

Facility

$0.21

Service Code	NDC 9994-3000-03
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 BICARBONATE 325 MG TABLET [7311]

Facility

$0.06

Service Code	NDC 0223-1720-01
Hospital Charge Code	1711142
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 BICARBONATE 325 MG TABLET [7311]

Facility

$0.02

Service Code	NDC 0536-1046-10
Hospital Charge Code	1711142
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 BICARBONATE 325 MG TABLET [7311]

Facility

$0.06

Service Code	NDC 0223-1720-01
Hospital Charge Code	1711142
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 BICARBONATE 325 MG TABLET [7311]

Facility

$0.02

Service Code	NDC 0536-1046-10
Hospital Charge Code	1711142
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 BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE [7306]

Facility

$1.99

Service Code	NDC 0409-5534-24
Hospital Charge Code	1721156
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.19
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: Multiplan Beech St/Commercial/PHCS	$1.49

SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE [7306]

Facility

$1.99

Service Code	NDC 0409-5534-24
Hospital Charge Code	1721156
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.59
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.59
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.49

SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [111085]

Facility

$1.86

Service Code	NDC 0409-5555-12
Hospital Charge Code	1720926
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.12
Rate for Payer: Aetna of CA Government/Medicare	$1.12
Rate for Payer: Cash Price	$0.84
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.40

SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [111085]

Facility

$1.86

Service Code	NDC 0409-5555-12
Hospital Charge Code	1720926
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.49
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna of CA HMO/PPO	$1.49
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.40

SODIUM BICARBONATE 50 MEQ/50 ML SYRINGE - CODE [4080571]

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 BICARBONATE 50 MEQ/50 ML SYRINGE - CODE [4080571]

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 BICARBONATE 50 MEQ/50 ML VIAL - CODE [4080572]

Facility

$0.21

Service Code	NDC 51754-5001-5
Hospital Charge Code	1720286
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

SODIUM BICARBONATE 50 MEQ/50 ML VIAL - CODE [4080572]

Facility

$0.24

Service Code	NDC 0409-6625-22
Hospital Charge Code	1720286
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

Know your out-of-pocket cost for care.

All Charges