Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION [7536]

Facility

$1.02

Service Code	CPT J0330
Hospital Charge Code	1720071
Hospital Revenue Code	636
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$1.00
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS INJECTION. [408216150]

Facility

$1.98

Service Code	CPT J0330
Hospital Charge Code	NDG216150A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Smart Auto/Commercial	$0.72
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.48

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS INJECTION. [408216150]

Facility

$1.98

Service Code	CPT J0330
Hospital Charge Code	NDG216150A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Cash Price	$0.89
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$1.58
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.48

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS SYRINGE [216150]

Facility

$4.55

Service Code	CPT J0330
Hospital Charge Code	NDG216150A
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.73
Rate for Payer: Aetna of CA Government/Medicare	$2.73
Rate for Payer: Cash Price	$2.05
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.73
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.41

SUCCINYLCHOLINE(PF)100 MG/5 ML (20 MG/ML)-NACL,ISO INTRAVENOUS SYRINGE [216150]

Facility

$4.55

Service Code	CPT J0330
Hospital Charge Code	NDG216150A
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.64
Rate for Payer: Cash Price	$2.05
Rate for Payer: Cigna of CA HMO/PPO	$3.64
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.41

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.09

Service Code	NDC 68094-043-62
Hospital Charge Code	1716079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.09

Service Code	NDC 0121-0974-94
Hospital Charge Code	1716079
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

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.08

Service Code	NDC 0121-0974-10
Hospital Charge Code	1716079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.09

Service Code	NDC 68094-043-62
Hospital Charge Code	1716079
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

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.08

Service Code	NDC 0121-0974-10
Hospital Charge Code	1716079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.09

Service Code	NDC 0121-0974-94
Hospital Charge Code	1716079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.08

Service Code	NDC 68094-043-59
Hospital Charge Code	1716079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

SUCRALFATE 100 MG/ML ORAL SUSPENSION [11441]

Facility

$1.08

Service Code	NDC 68094-043-59
Hospital Charge Code	1716079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.81

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.32

Service Code	NDC 0093-2210-01
Hospital Charge Code	1712027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.32

Service Code	NDC 0093-2210-01
Hospital Charge Code	1712027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.24

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.18

Service Code	NDC 59762-0401-5
Hospital Charge Code	1712027
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

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.18

Service Code	NDC 59762-0401-5
Hospital Charge Code	1712027
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

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$5.67

Service Code	NDC 58914-171-10
Hospital Charge Code	1712027
Hospital Revenue Code	259
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.40
Rate for Payer: Aetna of CA Government/Medicare	$3.40
Rate for Payer: Cash Price	$2.55
Rate for Payer: Health Smart Auto/Commercial	$3.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.40
Rate for Payer: LLUH Dept of Risk Management WC	$3.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.25

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.19

Service Code	NDC 59762-0401-1
Hospital Charge Code	1712027
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	$0.09
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

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.38

Service Code	NDC 51079-753-01
Hospital Charge Code	1712027
Hospital Revenue Code	259
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	$0.17
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

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$5.67

Service Code	NDC 58914-171-10
Hospital Charge Code	1712027
Hospital Revenue Code	259
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$4.54
Rate for Payer: Cash Price	$2.55
Rate for Payer: Cigna of CA HMO/PPO	$4.54
Rate for Payer: Health Smart Auto/Commercial	$3.40
Rate for Payer: LLUH Dept of Risk Management WC	$3.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.25

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.38

Service Code	NDC 51079-753-01
Hospital Charge Code	1712027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
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

SUCRALFATE 1 GRAM TABLET [11442]

Facility

$0.19

Service Code	NDC 59762-0401-1
Hospital Charge Code	1712027
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

SUCROSE 24 % ORAL SOLUTION [40840035]

Facility

$5.00

Service Code	NDC 9940-8400-35
Hospital Charge Code	1774022
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

SUCROSE 24 % ORAL SOLUTION [40840035]

Facility

$5.00

Service Code	NDC 9940-8400-35
Hospital Charge Code	1774022
Hospital Revenue Code	259
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cigna of CA HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

Know your out-of-pocket cost for care.

All Charges