Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]

Facility

$1.09

Service Code	NDC 46287-006-04
Hospital Charge Code	1748079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]

Facility

$0.49

Service Code	NDC 1011905220
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

SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]

Facility

$0.49

Service Code	NDC 1011905220
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

SOLIFENACIN 5 MG TABLET [40392]

Facility

$0.48

Service Code	NDC 67877-527-30
Hospital Charge Code	1710977
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.36
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	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

SOLIFENACIN 5 MG TABLET [40392]

Facility

$0.48

Service Code	NDC 67877-527-30
Hospital Charge Code	1710977
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.36

SOMATROPIN 1 MG/ML SOLUTION FOR INJECTION [408114182]

Facility

$844.08

Service Code	CPT J2941
Hospital Charge Code	NDG40811418
Hospital Revenue Code	636
Min. Negotiated Rate	$464.24
Max. Negotiated Rate	$675.26
Rate for Payer: Cash Price	$379.84
Rate for Payer: Cigna of CA HMO/PPO	$675.26
Rate for Payer: Health Smart Auto/Commercial	$506.45
Rate for Payer: LLUH Dept of Risk Management WC	$464.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$633.06

SOMATROPIN 1 MG/ML SOLUTION FOR INJECTION [408114182]

Facility

$844.08

Service Code	CPT J2941
Hospital Charge Code	NDG40811418
Hospital Revenue Code	636
Min. Negotiated Rate	$464.24
Max. Negotiated Rate	$633.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$506.45
Rate for Payer: Aetna of CA Government/Medicare	$506.45
Rate for Payer: Cash Price	$379.84
Rate for Payer: Health Smart Auto/Commercial	$506.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$506.45
Rate for Payer: LLUH Dept of Risk Management WC	$464.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$633.06

SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]

Facility

$614.28

Service Code	CPT J2941
Hospital Charge Code	NDG117385
Hospital Revenue Code	636
Min. Negotiated Rate	$337.85
Max. Negotiated Rate	$491.42
Rate for Payer: Cash Price	$276.43
Rate for Payer: Cigna of CA HMO/PPO	$491.42
Rate for Payer: Health Smart Auto/Commercial	$368.57
Rate for Payer: LLUH Dept of Risk Management WC	$337.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$460.71

SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]

Facility

$614.28

Service Code	CPT J2941
Hospital Charge Code	NDG117385
Hospital Revenue Code	636
Min. Negotiated Rate	$337.85
Max. Negotiated Rate	$460.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$368.57
Rate for Payer: Aetna of CA Government/Medicare	$368.57
Rate for Payer: Cash Price	$276.43
Rate for Payer: Health Smart Auto/Commercial	$368.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$368.57
Rate for Payer: LLUH Dept of Risk Management WC	$337.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$460.71

SOMATROPIN 6 MG (18 UNIT) INJECTION CARTRIDGE [14721]

Facility

$1,116.72

Service Code	CPT J2941
Hospital Charge Code	ERX14721
Hospital Revenue Code	636
Min. Negotiated Rate	$614.20
Max. Negotiated Rate	$837.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$670.03
Rate for Payer: Aetna of CA Government/Medicare	$670.03
Rate for Payer: Cash Price	$502.52
Rate for Payer: Health Smart Auto/Commercial	$670.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$670.03
Rate for Payer: LLUH Dept of Risk Management WC	$614.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$837.54

SOMATROPIN 6 MG (18 UNIT) INJECTION CARTRIDGE [14721]

Facility

$1,116.72

Service Code	CPT J2941
Hospital Charge Code	ERX14721
Hospital Revenue Code	636
Min. Negotiated Rate	$614.20
Max. Negotiated Rate	$893.38
Rate for Payer: Cash Price	$502.52
Rate for Payer: Cigna of CA HMO/PPO	$893.38
Rate for Payer: Health Smart Auto/Commercial	$670.03
Rate for Payer: LLUH Dept of Risk Management WC	$614.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$837.54

SOMATROPIN INJECTION 5 MG/2 ML FOR NICU SPEC DIL [40811418]

Facility

$844.08

Service Code	CPT J2941
Hospital Charge Code	NDG40811418
Hospital Revenue Code	636
Min. Negotiated Rate	$464.24
Max. Negotiated Rate	$633.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$506.45
Rate for Payer: Aetna of CA Government/Medicare	$506.45
Rate for Payer: Cash Price	$379.84
Rate for Payer: Health Smart Auto/Commercial	$506.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$506.45
Rate for Payer: LLUH Dept of Risk Management WC	$464.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$633.06

SOMATROPIN INJECTION 5 MG/2 ML FOR NICU SPEC DIL [40811418]

Facility

$844.08

Service Code	CPT J2941
Hospital Charge Code	NDG40811418
Hospital Revenue Code	636
Min. Negotiated Rate	$464.24
Max. Negotiated Rate	$675.26
Rate for Payer: Cash Price	$379.84
Rate for Payer: Cigna of CA HMO/PPO	$675.26
Rate for Payer: Health Smart Auto/Commercial	$506.45
Rate for Payer: LLUH Dept of Risk Management WC	$464.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$633.06

SORAFENIB 200 MG TABLET [43675]

Facility

$240.70

Service Code	NDC 50419-488-58
Hospital Charge Code	1712493
Hospital Revenue Code	259
Min. Negotiated Rate	$132.38
Max. Negotiated Rate	$192.56
Rate for Payer: Cash Price	$108.32
Rate for Payer: Cigna of CA HMO/PPO	$192.56
Rate for Payer: Health Smart Auto/Commercial	$144.42
Rate for Payer: LLUH Dept of Risk Management WC	$132.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$180.52

SORAFENIB 200 MG TABLET [43675]

Facility

$240.70

Service Code	NDC 50419-488-58
Hospital Charge Code	1712493
Hospital Revenue Code	259
Min. Negotiated Rate	$132.38
Max. Negotiated Rate	$180.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$144.42
Rate for Payer: Aetna of CA Government/Medicare	$144.42
Rate for Payer: Cash Price	$108.32
Rate for Payer: Health Smart Auto/Commercial	$144.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$144.42
Rate for Payer: LLUH Dept of Risk Management WC	$132.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$180.52

SORBITOL 70 % SOLUTION [7413]

Facility

$0.02

Service Code	NDC 4628750001
Hospital Charge Code	NDG7413A
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

SORBITOL 70 % SOLUTION [7413]

Facility

$0.02

Service Code	NDC 4628750001
Hospital Charge Code	NDG7413A
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

SORBITOL 70 % SOLUTION [7413]

Facility

$0.01

Service Code	NDC 0121-0659-16
Hospital Charge Code	NDG7413A
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

SORBITOL 70 % SOLUTION [7413]

Facility

$0.01

Service Code	NDC 0121-0659-16
Hospital Charge Code	NDG7413A
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

SOTALOL 80 MG TABLET [11421]

Facility

$0.34

Service Code	NDC 60505-0080-0
Hospital Charge Code	1711560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

SOTALOL 80 MG TABLET [11421]

Facility

$0.58

Service Code	NDC 0378-5123-01
Hospital Charge Code	1711560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

SOTALOL 80 MG TABLET [11421]

Facility

$0.34

Service Code	NDC 60505-0080-0
Hospital Charge Code	1711560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

SOTALOL 80 MG TABLET [11421]

Facility

$0.34

Service Code	NDC 76385-114-01
Hospital Charge Code	1711560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

SOTALOL 80 MG TABLET [11421]

Facility

$1.53

Service Code	NDC 68084-654-11
Hospital Charge Code	1711560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.92
Rate for Payer: Aetna of CA Government/Medicare	$0.92
Rate for Payer: Cash Price	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.15

SOTALOL 80 MG TABLET [11421]

Facility

$0.34

Service Code	NDC 76385-114-01
Hospital Charge Code	1711560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

Know your out-of-pocket cost for care.

All Charges