Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CLOZAPINE 100 MG TABLET [9647]

Facility

$1.31

Service Code	NDC 65862-846-01
Hospital Charge Code	1712218
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

CLOZAPINE 100 MG TABLET [9647]

Facility

$1.99

Service Code	NDC 0093-7772-19
Hospital Charge Code	1712218
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Cash Price	$0.90
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: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.49

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.79

Service Code	NDC 60687-404-11
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.78

Service Code	NDC 51079-921-01
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.78

Service Code	NDC 51079-921-01
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.78

Service Code	NDC 51079-921-20
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.79

Service Code	NDC 60687-404-11
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.79

Service Code	NDC 60687-404-01
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.78

Service Code	NDC 51079-921-20
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 25 MG TABLET [9648]

Facility

$0.79

Service Code	NDC 60687-404-01
Hospital Charge Code	1712217
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

CLOZAPINE 50 MG TABLET [41637]

Facility

$1.58

Service Code	NDC 0093-4404-01
Hospital Charge Code	ERX41637
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.95
Rate for Payer: Aetna of CA Government/Medicare	$0.95
Rate for Payer: Cash Price	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.18

CLOZAPINE 50 MG TABLET [41637]

Facility

$1.58

Service Code	NDC 0093-4404-01
Hospital Charge Code	ERX41637
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.71
Rate for Payer: Cigna of CA HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.18

COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [203437]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX19814
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.16
Rate for Payer: Aetna of CA Government/Medicare	$1.16
Rate for Payer: Cash Price	$0.87
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [203437]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX19814
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 2,000 UNIT INTRAVENOUS SOLUTION [203438]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203438
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.16
Rate for Payer: Aetna of CA Government/Medicare	$1.16
Rate for Payer: Cash Price	$0.87
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 2,000 UNIT INTRAVENOUS SOLUTION [203438]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203438
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 250 UNIT INTRAVENOUS SOLUTION [203435]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203435
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 250 UNIT INTRAVENOUS SOLUTION [203435]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203435
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.16
Rate for Payer: Aetna of CA Government/Medicare	$1.16
Rate for Payer: Cash Price	$0.87
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [203439]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203439
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.16
Rate for Payer: Aetna of CA Government/Medicare	$1.16
Rate for Payer: Cash Price	$0.87
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [203439]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203439
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION [203436]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203436
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION [203436]

Facility

$1.93

Service Code	CPT J7195
Hospital Charge Code	ERX203436
Hospital Revenue Code	636
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.16
Rate for Payer: Aetna of CA Government/Medicare	$1.16
Rate for Payer: Cash Price	$0.87
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION [92853]

Facility

$3.08

Service Code	CPT J7189
Hospital Charge Code	ERX92853
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.85
Rate for Payer: Aetna of CA Government/Medicare	$1.85
Rate for Payer: Cash Price	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.31

COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION [92853]

Facility

$3.08

Service Code	CPT J7189
Hospital Charge Code	ERX92853
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Cash Price	$1.39
Rate for Payer: Cigna of CA HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.31

COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION [92854]

Facility

$3.08

Service Code	CPT J7189
Hospital Charge Code	ERX92854
Hospital Revenue Code	636
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.85
Rate for Payer: Aetna of CA Government/Medicare	$1.85
Rate for Payer: Cash Price	$1.39
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.31

Know your out-of-pocket cost for care.

All Charges