Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SULFASALAZINE 500 MG TABLET [7562]

Facility

$0.48

Service Code	NDC 50268-730-11
Hospital Charge Code	1712415
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

SULFASALAZINE 500 MG TABLET [7562]

Facility

$0.48

Service Code	NDC 50268-730-11
Hospital Charge Code	1712415
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

SULFASALAZINE 500 MG TABLET [7562]

Facility

$0.22

Service Code	NDC 59762-5000-5
Hospital Charge Code	1712415
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
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	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

SULFASALAZINE 500 MG TABLET [7562]

Facility

$0.22

Service Code	NDC 59762-5000-5
Hospital Charge Code	1712415
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

SULFASALAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080342]

Facility

$0.05

Service Code	NDC 9994-0803-42
Hospital Charge Code	1715670
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

SULFASALAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080342]

Facility

$0.05

Service Code	NDC 9994-0803-42
Hospital Charge Code	1715670
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION [211119]

Facility

$0.09

Service Code	CPT Q9950
Hospital Charge Code	NDG211119
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION [211119]

Facility

$0.09

Service Code	CPT Q9950
Hospital Charge Code	NDG211119
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

SULINDAC 200 MG TABLET [7579]

Facility

$0.37

Service Code	NDC 42806-011-01
Hospital Charge Code	1710768
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
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	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

SULINDAC 200 MG TABLET [7579]

Facility

$0.37

Service Code	NDC 42806-011-01
Hospital Charge Code	1710768
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$2.13

Service Code	NDC 55111-293-09
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$0.80

Service Code	NDC 65862-148-36
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$2.13

Service Code	NDC 55111-293-09
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cigna of CA HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$0.80

Service Code	NDC 65862-148-36
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$1.25

Service Code	NDC 0378-5632-59
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.75
Rate for Payer: Aetna of CA Government/Medicare	$0.75
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$2.13

Service Code	NDC 62756-522-69
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$1.25

Service Code	NDC 0378-5632-59
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$1.00
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.94

SUMATRIPTAN 100 MG TABLET [13369]

Facility

$2.13

Service Code	NDC 62756-522-69
Hospital Charge Code	1711995
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cigna of CA HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY [20039]

Facility

$59.04

Service Code	NDC 0781-6523-06
Hospital Charge Code	1740304
Hospital Revenue Code	259
Min. Negotiated Rate	$32.47
Max. Negotiated Rate	$44.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.42
Rate for Payer: Aetna of CA Government/Medicare	$35.42
Rate for Payer: Cash Price	$26.57
Rate for Payer: Health Smart Auto/Commercial	$35.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.42
Rate for Payer: LLUH Dept of Risk Management WC	$32.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.28

SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY [20039]

Facility

$59.04

Service Code	NDC 0781-6523-06
Hospital Charge Code	1740304
Hospital Revenue Code	259
Min. Negotiated Rate	$32.47
Max. Negotiated Rate	$47.23
Rate for Payer: Cash Price	$26.57
Rate for Payer: Cigna of CA HMO/PPO	$47.23
Rate for Payer: Health Smart Auto/Commercial	$35.42
Rate for Payer: LLUH Dept of Risk Management WC	$32.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.28

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 55111-291-09
Hospital Charge Code	1712200
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cigna of CA HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$0.40

Service Code	NDC 65862-146-36
Hospital Charge Code	1712200
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 62756-520-69
Hospital Charge Code	1712200
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$2.13

Service Code	NDC 55111-291-09
Hospital Charge Code	1712200
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

SUMATRIPTAN 25 MG TABLET [15327]

Facility

$0.40

Service Code	NDC 65862-146-36
Hospital Charge Code	1712200
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

Know your out-of-pocket cost for care.

All Charges