Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SUCROSE 24 % ORAL SOLUTION [40840035]

Facility

$5.00

Service Code	NDC 0906-9904-41
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

SUCROSE 24 % ORAL SOLUTION [40840035]

Facility

$5.00

Service Code	NDC 0906-9904-41
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

SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]

Facility

$4.55

Service Code	NDC 17478-050-02
Hospital Charge Code	1737029
Hospital Revenue Code	250
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

SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]

Facility

$5.38

Service Code	NDC 17478-050-01
Hospital Charge Code	1737028
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$4.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.23
Rate for Payer: Aetna of CA Government/Medicare	$3.23
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Smart Auto/Commercial	$3.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.04

SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]

Facility

$4.55

Service Code	NDC 17478-050-02
Hospital Charge Code	1737029
Hospital Revenue Code	250
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$3.64
Rate for Payer: Health Smart Auto/Commercial	$2.73
Rate for Payer: Cash Price	$2.05
Rate for Payer: Cigna of CA HMO/PPO	$3.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.41

SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]

Facility

$5.38

Service Code	NDC 17478-050-01
Hospital Charge Code	1737028
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$4.30
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cigna of CA HMO/PPO	$4.30
Rate for Payer: Health Smart Auto/Commercial	$3.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.04

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]

Facility

$74.10

Service Code	CPT J3490
Hospital Charge Code	NDG212612A
Hospital Revenue Code	636
Min. Negotiated Rate	$40.76
Max. Negotiated Rate	$59.28
Rate for Payer: Cash Price	$33.35
Rate for Payer: Cigna of CA HMO/PPO	$59.28
Rate for Payer: Health Smart Auto/Commercial	$44.46
Rate for Payer: LLUH Dept of Risk Management WC	$40.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.58

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]

Facility

$74.10

Service Code	CPT J3490
Hospital Charge Code	NDG212612A
Hospital Revenue Code	636
Min. Negotiated Rate	$40.76
Max. Negotiated Rate	$55.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.46
Rate for Payer: Aetna of CA Government/Medicare	$44.46
Rate for Payer: Cash Price	$33.35
Rate for Payer: Health Smart Auto/Commercial	$44.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.46
Rate for Payer: LLUH Dept of Risk Management WC	$40.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.58

SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]

Facility

$38.50

Service Code	NDC 11980-022-10
Hospital Charge Code	1740029
Hospital Revenue Code	259
Min. Negotiated Rate	$21.18
Max. Negotiated Rate	$28.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.10
Rate for Payer: Aetna of CA Government/Medicare	$23.10
Rate for Payer: Cash Price	$17.33
Rate for Payer: Health Smart Auto/Commercial	$23.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$21.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.88

SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]

Facility

$38.50

Service Code	NDC 11980-022-10
Hospital Charge Code	1740029
Hospital Revenue Code	259
Min. Negotiated Rate	$21.18
Max. Negotiated Rate	$30.80
Rate for Payer: Cash Price	$17.33
Rate for Payer: Cigna of CA HMO/PPO	$30.80
Rate for Payer: Health Smart Auto/Commercial	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$21.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.88

SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]

Facility

$38.50

Service Code	NDC 11980-022-05
Hospital Charge Code	1740022
Hospital Revenue Code	259
Min. Negotiated Rate	$21.18
Max. Negotiated Rate	$28.88
Rate for Payer: Health Smart Auto/Commercial	$23.10
Rate for Payer: Cash Price	$17.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.10
Rate for Payer: Aetna of CA Government/Medicare	$23.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$21.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.88

SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]

Facility

$38.50

Service Code	NDC 11980-022-05
Hospital Charge Code	1740022
Hospital Revenue Code	259
Min. Negotiated Rate	$21.18
Max. Negotiated Rate	$30.80
Rate for Payer: Cash Price	$17.33
Rate for Payer: Cigna of CA HMO/PPO	$30.80
Rate for Payer: Health Smart Auto/Commercial	$23.10
Rate for Payer: LLUH Dept of Risk Management WC	$21.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.88

SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]

Facility

$3.60

Service Code	NDC 24208-317-05
Hospital Charge Code	NDG70392B
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cigna of CA HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]

Facility

$3.60

Service Code	NDC 24208-317-05
Hospital Charge Code	NDG70392B
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$33.51

Service Code	NDC 11980-011-05
Hospital Charge Code	1740256
Hospital Revenue Code	259
Min. Negotiated Rate	$18.43
Max. Negotiated Rate	$26.81
Rate for Payer: Cash Price	$15.08
Rate for Payer: Cigna of CA HMO/PPO	$26.81
Rate for Payer: Health Smart Auto/Commercial	$20.11
Rate for Payer: LLUH Dept of Risk Management WC	$18.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.13

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$3.90

Service Code	NDC 24208-670-04
Hospital Charge Code	1740173
Hospital Revenue Code	259
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of CA HMO/PPO	$3.12
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.92

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$3.90

Service Code	NDC 24208-670-04
Hospital Charge Code	1740173
Hospital Revenue Code	259
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$2.92
Rate for Payer: Health Smart Auto/Commercial	$2.34
Rate for Payer: Cash Price	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.34
Rate for Payer: Aetna of CA Government/Medicare	$2.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.34
Rate for Payer: LLUH Dept of Risk Management WC	$2.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.92

SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]

Facility

$33.51

Service Code	NDC 11980-011-05
Hospital Charge Code	1740256
Hospital Revenue Code	259
Min. Negotiated Rate	$18.43
Max. Negotiated Rate	$25.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.11
Rate for Payer: Aetna of CA Government/Medicare	$20.11
Rate for Payer: Cash Price	$15.08
Rate for Payer: Health Smart Auto/Commercial	$20.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.11
Rate for Payer: LLUH Dept of Risk Management WC	$18.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.13

SULFADIAZINE 500 MG TABLET [7554]

Facility

$4.85

Service Code	NDC 0185-0757-01
Hospital Charge Code	1710652
Hospital Revenue Code	259
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cigna of CA HMO/PPO	$3.88
Rate for Payer: Health Smart Auto/Commercial	$2.91
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.64

SULFADIAZINE 500 MG TABLET [7554]

Facility

$4.85

Service Code	NDC 0185-0757-01
Hospital Charge Code	1710652
Hospital Revenue Code	259
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.91
Rate for Payer: Aetna of CA Government/Medicare	$2.91
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Smart Auto/Commercial	$2.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.91
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.64

SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]

Facility

$0.72

Service Code	NDC 9994-0803-41
Hospital Charge Code	1715994
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]

Facility

$0.72

Service Code	NDC 9994-0803-41
Hospital Charge Code	1715994
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]

Facility

$0.10

Service Code	NDC 0121-0854-16
Hospital Charge Code	NDG22560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]

Facility

$0.11

Service Code	NDC 65862-496-47
Hospital Charge Code	NDG22560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]

Facility

$0.23

Service Code	NDC 50383-823-16
Hospital Charge Code	NDG22560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

Know your out-of-pocket cost for care.

All Charges