Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]

Facility

$0.13

Service Code	NDC 9994-0803-38
Hospital Charge Code	1715999
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

SOTALOL ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]

Facility

$0.13

Service Code	NDC 9994-0803-38
Hospital Charge Code	1715999
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

SOTORASIB 120 MG TABLET [231933]

Facility

$100.55

Service Code	NDC 55513-488-40
Hospital Charge Code	ERX231933
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$80.44
Rate for Payer: Cash Price	$45.25
Rate for Payer: Cigna of CA HMO/PPO	$80.44
Rate for Payer: Health Smart Auto/Commercial	$60.33
Rate for Payer: LLUH Dept of Risk Management WC	$55.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.41

SOTORASIB 120 MG TABLET [231933]

Facility

$100.55

Service Code	NDC 55513-488-24
Hospital Charge Code	ERX231933
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$75.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.33
Rate for Payer: Aetna of CA Government/Medicare	$60.33
Rate for Payer: Cash Price	$45.25
Rate for Payer: Health Smart Auto/Commercial	$60.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.33
Rate for Payer: LLUH Dept of Risk Management WC	$55.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.41

SOTORASIB 120 MG TABLET [231933]

Facility

$100.55

Service Code	NDC 55513-488-40
Hospital Charge Code	ERX231933
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$75.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.33
Rate for Payer: Aetna of CA Government/Medicare	$60.33
Rate for Payer: Cash Price	$45.25
Rate for Payer: Health Smart Auto/Commercial	$60.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.33
Rate for Payer: LLUH Dept of Risk Management WC	$55.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.41

SOTORASIB 120 MG TABLET [231933]

Facility

$100.55

Service Code	NDC 55513-488-24
Hospital Charge Code	ERX231933
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$80.44
Rate for Payer: Cash Price	$45.25
Rate for Payer: Cigna of CA HMO/PPO	$80.44
Rate for Payer: Health Smart Auto/Commercial	$60.33
Rate for Payer: LLUH Dept of Risk Management WC	$55.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.41

SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) INTRAVENOUS SOLUTION (EUA) [231935]

Facility

$315.00

Service Code	CPT Q0247
Hospital Charge Code	NDG231935
Hospital Revenue Code	636
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$252.00
Rate for Payer: Cash Price	$141.75
Rate for Payer: Cigna of CA HMO/PPO	$252.00
Rate for Payer: Health Smart Auto/Commercial	$189.00
Rate for Payer: LLUH Dept of Risk Management WC	$173.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$236.25

SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) INTRAVENOUS SOLUTION (EUA) [231935]

Facility

$315.00

Service Code	CPT Q0247
Hospital Charge Code	NDG231935
Hospital Revenue Code	636
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$236.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$189.00
Rate for Payer: Aetna of CA Government/Medicare	$189.00
Rate for Payer: Cash Price	$141.75
Rate for Payer: Health Smart Auto/Commercial	$189.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$189.00
Rate for Payer: LLUH Dept of Risk Management WC	$173.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$236.25

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.64

Service Code	NDC 53746-515-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.64

Service Code	NDC 16729-227-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.57

Service Code	NDC 53489-329-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
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	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.43

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.64

Service Code	NDC 16729-227-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.47

Service Code	NDC 59746-218-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
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	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.57

Service Code	NDC 53489-329-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.43

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.64

Service Code	NDC 53746-515-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

SPIRONOLACTONE 100 MG TABLET [11425]

Facility

$0.47

Service Code	NDC 59746-218-01
Hospital Charge Code	1710137
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

SPIRONOLACTONE 12.5 MG 1/2 TABLET [4081582]

Facility

$0.07

Service Code	NDC 9994-0815-82
Hospital Charge Code	ERX4081582
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

SPIRONOLACTONE 12.5 MG 1/2 TABLET [4081582]

Facility

$0.07

Service Code	NDC 9994-0815-82
Hospital Charge Code	ERX4081582
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

SPIRONOLACTONE 25 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [7439]

Facility

$1.46

Service Code	NDC 53489-144-01
Hospital Charge Code	1711768
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.88
Rate for Payer: Aetna of CA Government/Medicare	$0.88
Rate for Payer: Cash Price	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.10

SPIRONOLACTONE 25 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [7439]

Facility

$1.46

Service Code	NDC 53489-144-01
Hospital Charge Code	1711768
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.17
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cigna of CA HMO/PPO	$1.17
Rate for Payer: Health Smart Auto/Commercial	$0.88
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.10

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

$0.23

Service Code	NDC 60687-465-01
Hospital Charge Code	1710088
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

$0.15

Service Code	NDC 68382-660-01
Hospital Charge Code	1710088
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

SPIRONOLACTONE 25 MG TABLET [7437]

Facility

$0.19

Service Code	NDC 0378-2146-01
Hospital Charge Code	1710088
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
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

Know your out-of-pocket cost for care.

All Charges