Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$16.24
Rate for Payer: Cash Price	$9.14
Rate for Payer: Cigna of CA HMO/PPO	$16.24
Rate for Payer: Health Smart Auto/Commercial	$12.18
Rate for Payer: LLUH Dept of Risk Management WC	$11.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.22

SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]

Facility

$61.48

Service Code	NDC 75987-070-09
Hospital Charge Code	ERX17601A
Hospital Revenue Code	259
Min. Negotiated Rate	$33.81
Max. Negotiated Rate	$49.18
Rate for Payer: Cash Price	$27.67
Rate for Payer: Cigna of CA HMO/PPO	$49.18
Rate for Payer: Health Smart Auto/Commercial	$36.89
Rate for Payer: LLUH Dept of Risk Management WC	$33.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$46.11

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

SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]

Facility

$56.63

Service Code	NDC 38779-3207-8
Hospital Charge Code	NDG77481A
Hospital Revenue Code	259
Min. Negotiated Rate	$31.15
Max. Negotiated Rate	$45.30
Rate for Payer: Cash Price	$25.48
Rate for Payer: Cigna of CA HMO/PPO	$45.30
Rate for Payer: Health Smart Auto/Commercial	$33.98
Rate for Payer: LLUH Dept of Risk Management WC	$31.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.47

SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]

Facility

$56.63

Service Code	NDC 38779-3207-8
Hospital Charge Code	NDG77481A
Hospital Revenue Code	259
Min. Negotiated Rate	$31.15
Max. Negotiated Rate	$42.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.98
Rate for Payer: Aetna of CA Government/Medicare	$33.98
Rate for Payer: Cash Price	$25.48
Rate for Payer: Health Smart Auto/Commercial	$33.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.98
Rate for Payer: LLUH Dept of Risk Management WC	$31.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.47

SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]

Facility

$0.04

Service Code	NDC 9994-0803-37
Hospital Charge Code	NDG4080337
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

SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]

Facility

$0.04

Service Code	NDC 9994-0803-37
Hospital Charge Code	NDG4080337
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

SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]

Facility

$0.07

Service Code	NDC 9994-0804-45
Hospital Charge Code	1715308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]

Facility

$0.07

Service Code	NDC 9994-0804-45
Hospital Charge Code	1715308
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]

Facility

$0.01

Service Code	NDC 0132-0201-40
Hospital Charge Code	1748014
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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: 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	$0.01

SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]

Facility

$0.01

Service Code	NDC 0536-7415-51
Hospital Charge Code	1748014
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
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	$0.01

SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]

Facility

$0.01

Service Code	NDC 0132-0201-40
Hospital Charge Code	1748014
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
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	$0.01

SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]

Facility

$0.01

Service Code	NDC 0536-7415-51
Hospital Charge Code	1748014
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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: 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	$0.01

SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [118601]

Facility

$0.02

Service Code	NDC 0132-0202-20
Hospital Charge Code	1748004
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 PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [118601]

Facility

$0.02

Service Code	NDC 0132-0202-20
Hospital Charge Code	1748004
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 POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]

Facility

$0.49

Service Code	NDC 46287-006-60
Hospital Charge Code	1719164
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]

Facility

$0.50

Service Code	NDC 46287-006-01
Hospital Charge Code	1715036
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]

Facility

$0.49

Service Code	NDC 46287-006-60
Hospital Charge Code	1719164
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]

Facility

$0.50

Service Code	NDC 46287-006-01
Hospital Charge Code	1715036
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]

Facility

$0.18

Service Code	NDC 9999-9973-56
Hospital Charge Code	NDG7356
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]

Facility

$0.18

Service Code	NDC 9994-0821-06
Hospital Charge Code	NDG7356
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]

Facility

$0.35

Service Code	NDC 42806-013-96
Hospital Charge Code	1713002
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]

Facility

$0.27

Service Code	NDC 51293-831-97
Hospital Charge Code	NDG7356A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]

Facility

$0.35

Service Code	NDC 11534-166-44
Hospital Charge Code	1713002
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]

Facility

$0.18

Service Code	NDC 9994-0821-06
Hospital Charge Code	NDG7356
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

Know your out-of-pocket cost for care.

All Charges