Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$1.70
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 50 MG TABLET [15328]

Facility

$2.13

Service Code	NDC 62756-521-69
Hospital Charge Code	1712201
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 50 MG TABLET [15328]

Facility

$2.13

Service Code	NDC 62756-521-69
Hospital Charge Code	1712201
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 50 MG TABLET [15328]

Facility

$0.53

Service Code	NDC 65862-147-36
Hospital Charge Code	1712201
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$2.11

Service Code	NDC 63304-098-19
Hospital Charge Code	1712201
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.58

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$0.53

Service Code	NDC 65862-147-36
Hospital Charge Code	1712201
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.40

SUMATRIPTAN 50 MG TABLET [15328]

Facility

$2.11

Service Code	NDC 63304-098-19
Hospital Charge Code	1712201
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.69
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cigna of CA HMO/PPO	$1.69
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.58

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]

Facility

$183.60

Service Code	CPT J3030
Hospital Charge Code	NDG11467B
Hospital Revenue Code	636
Min. Negotiated Rate	$100.98
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.16
Rate for Payer: Aetna of CA Government/Medicare	$110.16
Rate for Payer: Cash Price	$82.62
Rate for Payer: Health Smart Auto/Commercial	$110.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.16
Rate for Payer: LLUH Dept of Risk Management WC	$100.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$137.70

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]

Facility

$183.60

Service Code	CPT J3030
Hospital Charge Code	NDG11467B
Hospital Revenue Code	636
Min. Negotiated Rate	$100.98
Max. Negotiated Rate	$146.88
Rate for Payer: Cash Price	$82.62
Rate for Payer: Cigna of CA HMO/PPO	$146.88
Rate for Payer: Health Smart Auto/Commercial	$110.16
Rate for Payer: LLUH Dept of Risk Management WC	$100.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$137.70

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]

Facility

$163.52

Service Code	CPT J3030
Hospital Charge Code	1721041
Hospital Revenue Code	636
Min. Negotiated Rate	$89.94
Max. Negotiated Rate	$122.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$98.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.56
Rate for Payer: Aetna of CA Government/Medicare	$98.11
Rate for Payer: Aetna of CA Government/Medicare	$15.84
Rate for Payer: Aetna of CA Government/Medicare	$70.56
Rate for Payer: Cash Price	$11.88
Rate for Payer: Cash Price	$73.58
Rate for Payer: Cash Price	$52.92
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: Health Smart Auto/Commercial	$70.56
Rate for Payer: Health Smart Auto/Commercial	$98.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$98.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.56
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: LLUH Dept of Risk Management WC	$64.68
Rate for Payer: LLUH Dept of Risk Management WC	$89.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$122.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$88.20

SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]

Facility

$163.52

Service Code	CPT J3030
Hospital Charge Code	1721041
Hospital Revenue Code	636
Min. Negotiated Rate	$89.94
Max. Negotiated Rate	$130.82
Rate for Payer: Cash Price	$73.58
Rate for Payer: Cash Price	$52.92
Rate for Payer: Cash Price	$11.88
Rate for Payer: Cigna of CA HMO/PPO	$130.82
Rate for Payer: Cigna of CA HMO/PPO	$21.12
Rate for Payer: Cigna of CA HMO/PPO	$94.08
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: Health Smart Auto/Commercial	$98.11
Rate for Payer: Health Smart Auto/Commercial	$70.56
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: LLUH Dept of Risk Management WC	$64.68
Rate for Payer: LLUH Dept of Risk Management WC	$89.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$122.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$88.20

SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]

Facility

$1.26

Service Code	NDC 9994-0803-44
Hospital Charge Code	1715019
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.01
Rate for Payer: Cash Price	$0.57
Rate for Payer: Cigna of CA HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]

Facility

$1.26

Service Code	NDC 9994-0803-44
Hospital Charge Code	1715019
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Cash Price	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.95

SUNITINIB MALATE 12.5 MG CAPSULE [70424]

Facility

$268.64

Service Code	NDC 0069-0550-38
Hospital Charge Code	1712626
Hospital Revenue Code	259
Min. Negotiated Rate	$147.75
Max. Negotiated Rate	$201.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$161.18
Rate for Payer: Aetna of CA Government/Medicare	$161.18
Rate for Payer: Cash Price	$120.89
Rate for Payer: Health Smart Auto/Commercial	$161.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$161.18
Rate for Payer: LLUH Dept of Risk Management WC	$147.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.48

SUNITINIB MALATE 12.5 MG CAPSULE [70424]

Facility

$268.64

Service Code	NDC 0069-0550-38
Hospital Charge Code	1712626
Hospital Revenue Code	259
Min. Negotiated Rate	$147.75
Max. Negotiated Rate	$214.91
Rate for Payer: Cash Price	$120.89
Rate for Payer: Cigna of CA HMO/PPO	$214.91
Rate for Payer: Health Smart Auto/Commercial	$161.18
Rate for Payer: LLUH Dept of Risk Management WC	$147.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.48

SUNITINIB MALATE 25 MG CAPSULE [70425]

Facility

$537.29

Service Code	NDC 0069-0770-38
Hospital Charge Code	1712627
Hospital Revenue Code	259
Min. Negotiated Rate	$295.51
Max. Negotiated Rate	$429.83
Rate for Payer: Cash Price	$241.78
Rate for Payer: Cigna of CA HMO/PPO	$429.83
Rate for Payer: Health Smart Auto/Commercial	$322.37
Rate for Payer: LLUH Dept of Risk Management WC	$295.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$402.97

SUNITINIB MALATE 25 MG CAPSULE [70425]

Facility

$537.29

Service Code	NDC 0069-0770-38
Hospital Charge Code	1712627
Hospital Revenue Code	259
Min. Negotiated Rate	$295.51
Max. Negotiated Rate	$402.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$322.37
Rate for Payer: Aetna of CA Government/Medicare	$322.37
Rate for Payer: Cash Price	$241.78
Rate for Payer: Health Smart Auto/Commercial	$322.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$322.37
Rate for Payer: LLUH Dept of Risk Management WC	$295.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$402.97

SUNITINIB MALATE 50 MG CAPSULE [70426]

Facility

$935.35

Service Code	NDC 0069-0980-38
Hospital Charge Code	1711857
Hospital Revenue Code	259
Min. Negotiated Rate	$514.44
Max. Negotiated Rate	$748.28
Rate for Payer: Cash Price	$420.91
Rate for Payer: Cigna of CA HMO/PPO	$748.28
Rate for Payer: Health Smart Auto/Commercial	$561.21
Rate for Payer: LLUH Dept of Risk Management WC	$514.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$701.51

SUNITINIB MALATE 50 MG CAPSULE [70426]

Facility

$935.35

Service Code	NDC 0069-0980-38
Hospital Charge Code	1711857
Hospital Revenue Code	259
Min. Negotiated Rate	$514.44
Max. Negotiated Rate	$701.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$561.21
Rate for Payer: Aetna of CA Government/Medicare	$561.21
Rate for Payer: Cash Price	$420.91
Rate for Payer: Health Smart Auto/Commercial	$561.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$561.21
Rate for Payer: LLUH Dept of Risk Management WC	$514.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$701.51

SURGICAL LUBRICANT JELLY TOPICAL [112826]

Facility

$0.05

Service Code	NDC 281020545
Hospital Charge Code	NDG112826C
Hospital Revenue Code	250
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

SURGICAL LUBRICANT JELLY TOPICAL [112826]

Facility

$0.05

Service Code	NDC 281020545
Hospital Charge Code	NDG112826C
Hospital Revenue Code	250
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

TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]

Facility

$2.80

Service Code	NDC 45802-390-00
Hospital Charge Code	1743765
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.24
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cigna of CA HMO/PPO	$2.24
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.10

TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]

Facility

$2.80

Service Code	NDC 45802-390-00
Hospital Charge Code	1743765
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.10
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: Cash Price	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.68
Rate for Payer: Aetna of CA Government/Medicare	$1.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.10

TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]

Facility

$5.42

Service Code	NDC 0168-0416-60
Hospital Charge Code	NDG29443
Hospital Revenue Code	259
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$4.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.25
Rate for Payer: Aetna of CA Government/Medicare	$3.25
Rate for Payer: Cash Price	$2.44
Rate for Payer: Health Smart Auto/Commercial	$3.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.25
Rate for Payer: LLUH Dept of Risk Management WC	$2.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.06

TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]

Facility

$4.00

Service Code	NDC 68462-534-65
Hospital Charge Code	NDG29443
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

Know your out-of-pocket cost for care.

All Charges