Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]

Facility

$232.00

Service Code	NDC 8544636991
Hospital Charge Code	1796113
Hospital Revenue Code	272
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.20
Rate for Payer: Aetna of CA Government/Medicare	$139.20
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.00

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]

Facility

$232.00

Service Code	NDC 8544636991
Hospital Charge Code	1796113
Hospital Revenue Code	272
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna of CA HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.00

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]

Facility

$232.00

Service Code	CPT J3490
Hospital Charge Code	1796113
Hospital Revenue Code	636
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$185.60
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna of CA HMO/PPO	$185.60
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.00

SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]

Facility

$232.00

Service Code	CPT J3490
Hospital Charge Code	1796113
Hospital Revenue Code	636
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$139.20
Rate for Payer: Aetna of CA Government/Medicare	$139.20
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Smart Auto/Commercial	$139.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$139.20
Rate for Payer: LLUH Dept of Risk Management WC	$127.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$174.00

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.03

Service Code	NDC 3932806412
Hospital Charge Code	NDG76720
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

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.03

Service Code	NDC 3932806412
Hospital Charge Code	NDG76720
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

SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.02

Service Code	NDC 0436-0672-16
Hospital Charge Code	NDG76720
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 HYPOCHLORITE 0.125 % SOLUTION [76720]

Facility

$0.02

Service Code	NDC 0436-0672-16
Hospital Charge Code	NDG76720
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 HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.03

Service Code	NDC 39328-063-25
Hospital Charge Code	1743771
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

SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.02

Service Code	NDC 0436-0936-16
Hospital Charge Code	1743771
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 HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.02

Service Code	NDC 0436-0936-16
Hospital Charge Code	1743771
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 HYPOCHLORITE 0.25 % SOLUTION [15950]

Facility

$0.03

Service Code	NDC 39328-063-25
Hospital Charge Code	1743771
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.02

Service Code	NDC 0436-0946-16
Hospital Charge Code	1743772
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 HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.03

Service Code	NDC 39328-062-50
Hospital Charge Code	1743772
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.03

Service Code	NDC 39328-062-50
Hospital Charge Code	1743772
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

SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]

Facility

$0.02

Service Code	NDC 0436-0946-16
Hospital Charge Code	1743772
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 IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]

Facility

$1.20

Service Code	NDC 63323-019-10
Hospital Charge Code	NDG7344
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]

Facility

$1.20

Service Code	NDC 63323-019-10
Hospital Charge Code	NDG7344
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]

Facility

$442.90

Service Code	CPT A9516
Hospital Charge Code	ERX153922
Hospital Revenue Code	343
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$332.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$265.74
Rate for Payer: Aetna of CA Government/Medicare	$265.74
Rate for Payer: Cash Price	$199.31
Rate for Payer: Health Smart Auto/Commercial	$265.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$265.74
Rate for Payer: LLUH Dept of Risk Management WC	$243.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$332.18

SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]

Facility

$442.90

Service Code	CPT A9516
Hospital Charge Code	ERX153922
Hospital Revenue Code	343
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$354.32
Rate for Payer: Cash Price	$199.31
Rate for Payer: Cigna of CA HMO/PPO	$354.32
Rate for Payer: Health Smart Auto/Commercial	$265.74
Rate for Payer: LLUH Dept of Risk Management WC	$243.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$332.18

SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]

Facility

$12.00

Service Code	NDC 70069-261-01
Hospital Charge Code	1757922
Hospital Revenue Code	250
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna of CA HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]

Facility

$12.00

Service Code	NDC 70069-261-01
Hospital Charge Code	1757922
Hospital Revenue Code	250
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]

Facility

$78.00

Service Code	NDC 67457-839-02
Hospital Charge Code	1757922
Hospital Revenue Code	250
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$46.80
Rate for Payer: Aetna of CA Government/Medicare	$46.80
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$46.80
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$58.50

SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]

Facility

$78.00

Service Code	NDC 67457-839-02
Hospital Charge Code	1757922
Hospital Revenue Code	250
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$62.40
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna of CA HMO/PPO	$62.40
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$58.50

SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]

Facility

$20.30

Service Code	NDC 42794-086-14
Hospital Charge Code	ERX17601A
Hospital Revenue Code	259
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$15.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.18
Rate for Payer: Aetna of CA Government/Medicare	$12.18
Rate for Payer: Cash Price	$9.14
Rate for Payer: Health Smart Auto/Commercial	$12.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.18
Rate for Payer: LLUH Dept of Risk Management WC	$11.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.22

Know your out-of-pocket cost for care.

All Charges