Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$0.25

Service Code	NDC 43547-546-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$0.25

Service Code	NDC 51672-4038-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$0.25

Service Code	NDC 43547-546-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

ENALAPRIL MALEATE 5 MG TABLET [9927]

Facility

$0.25

Service Code	NDC 51672-4038-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]

Facility

$18.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.71
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$6.71
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.94
Rate for Payer: Health Smart Auto/Commercial	$6.71
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.71
Rate for Payer: LLUH Dept of Risk Management WC	$6.15
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$8.38

ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [105903]

Facility

$11.18

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$8.94
Rate for Payer: Cash Price	$6.15
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.94
Rate for Payer: Health Smart Auto/Commercial	$6.71
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$6.15
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$8.38
Rate for Payer: Multiplan Commercial	$13.50

ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]

Facility

$27.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.51
Rate for Payer: Aetna of CA Government/Medicare	$7.57
Rate for Payer: Aetna of CA Government/Medicare	$16.20
Rate for Payer: Aetna of CA Government/Medicare	$12.51
Rate for Payer: Cash Price	$6.94
Rate for Payer: Cash Price	$14.85
Rate for Payer: Cash Price	$11.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.68
Rate for Payer: Health Smart Auto/Commercial	$7.57
Rate for Payer: Health Smart Auto/Commercial	$12.51
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.20
Rate for Payer: LLUH Dept of Risk Management WC	$11.47
Rate for Payer: LLUH Dept of Risk Management WC	$6.94
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: Multiplan Commercial	$9.46
Rate for Payer: Multiplan Commercial	$15.64
Rate for Payer: Multiplan Commercial	$20.25

ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [105904]

Facility

$27.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$21.60
Rate for Payer: Cash Price	$14.85
Rate for Payer: Cash Price	$6.94
Rate for Payer: Cash Price	$11.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.10
Rate for Payer: Health Smart Auto/Commercial	$7.57
Rate for Payer: Health Smart Auto/Commercial	$12.51
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: LLUH Dept of Risk Management WC	$6.94
Rate for Payer: LLUH Dept of Risk Management WC	$11.47
Rate for Payer: Multiplan Commercial	$9.46
Rate for Payer: Multiplan Commercial	$15.64
Rate for Payer: Multiplan Commercial	$20.25

ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]

Facility

$16.75

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$13.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.20
Rate for Payer: Aetna of CA Government/Medicare	$16.20
Rate for Payer: Aetna of CA Government/Medicare	$10.05
Rate for Payer: Cash Price	$9.21
Rate for Payer: Cash Price	$14.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.60
Rate for Payer: Health Smart Auto/Commercial	$10.05
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.20
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.21
Rate for Payer: Multiplan Commercial	$12.56
Rate for Payer: Multiplan Commercial	$20.25

ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [31921]

Facility

$27.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$21.60
Rate for Payer: Cash Price	$14.85
Rate for Payer: Cash Price	$9.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.60
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Health Smart Auto/Commercial	$10.05
Rate for Payer: LLUH Dept of Risk Management WC	$9.21
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: Multiplan Commercial	$12.56
Rate for Payer: Multiplan Commercial	$20.25

ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION [105940]

Facility

$12.80

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$10.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.40
Rate for Payer: Aetna of CA Government/Medicare	$17.86
Rate for Payer: Aetna of CA Government/Medicare	$7.68
Rate for Payer: Aetna of CA Government/Medicare	$15.40
Rate for Payer: Cash Price	$7.04
Rate for Payer: Cash Price	$16.37
Rate for Payer: Cash Price	$14.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.53
Rate for Payer: Health Smart Auto/Commercial	$15.40
Rate for Payer: Health Smart Auto/Commercial	$17.86
Rate for Payer: Health Smart Auto/Commercial	$7.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.40
Rate for Payer: LLUH Dept of Risk Management WC	$16.37
Rate for Payer: LLUH Dept of Risk Management WC	$7.04
Rate for Payer: LLUH Dept of Risk Management WC	$14.11
Rate for Payer: Multiplan Commercial	$19.25
Rate for Payer: Multiplan Commercial	$22.33
Rate for Payer: Multiplan Commercial	$9.60

ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION [105940]

Facility

$12.80

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$10.24
Rate for Payer: Cash Price	$7.04
Rate for Payer: Cash Price	$16.37
Rate for Payer: Cash Price	$14.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.82
Rate for Payer: Health Smart Auto/Commercial	$15.40
Rate for Payer: Health Smart Auto/Commercial	$7.68
Rate for Payer: Health Smart Auto/Commercial	$17.86
Rate for Payer: LLUH Dept of Risk Management WC	$7.04
Rate for Payer: LLUH Dept of Risk Management WC	$16.37
Rate for Payer: LLUH Dept of Risk Management WC	$14.11
Rate for Payer: Multiplan Commercial	$19.25
Rate for Payer: Multiplan Commercial	$9.60
Rate for Payer: Multiplan Commercial	$22.33

ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]

Facility

$14.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.20
Rate for Payer: Cash Price	$7.70
Rate for Payer: Cash Price	$5.50
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.20
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Health Smart Auto/Commercial	$8.40
Rate for Payer: Health Smart Auto/Commercial	$6.65
Rate for Payer: LLUH Dept of Risk Management WC	$6.09
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: LLUH Dept of Risk Management WC	$7.70
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$8.31
Rate for Payer: Multiplan Commercial	$7.50
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$10.50

ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [105899]

Facility

$10.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$6.65
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$8.40
Rate for Payer: Cash Price	$5.50
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.09
Rate for Payer: Cash Price	$7.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$8.40
Rate for Payer: Health Smart Auto/Commercial	$6.65
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: LLUH Dept of Risk Management WC	$7.70
Rate for Payer: LLUH Dept of Risk Management WC	$6.09
Rate for Payer: Multiplan Commercial	$8.31
Rate for Payer: Multiplan Commercial	$10.50
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$7.50

ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]

Facility

$18.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.28
Rate for Payer: Aetna of CA Government/Medicare	$6.62
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$8.28
Rate for Payer: Cash Price	$6.07
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$7.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.04
Rate for Payer: Health Smart Auto/Commercial	$6.62
Rate for Payer: Health Smart Auto/Commercial	$8.28
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.59
Rate for Payer: LLUH Dept of Risk Management WC	$6.07
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$8.28
Rate for Payer: Multiplan Commercial	$10.35
Rate for Payer: Multiplan Commercial	$13.50

ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [105900]

Facility

$18.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.07
Rate for Payer: Cash Price	$7.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.83
Rate for Payer: Health Smart Auto/Commercial	$6.62
Rate for Payer: Health Smart Auto/Commercial	$8.28
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: LLUH Dept of Risk Management WC	$6.07
Rate for Payer: LLUH Dept of Risk Management WC	$7.59
Rate for Payer: Multiplan Commercial	$8.28
Rate for Payer: Multiplan Commercial	$10.35
Rate for Payer: Multiplan Commercial	$13.50

ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]

Facility

$29.80

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$23.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$6.44
Rate for Payer: Aetna of CA Government/Medicare	$17.88
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$5.91
Rate for Payer: Cash Price	$16.39
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$6.44
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$17.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.88
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.91
Rate for Payer: LLUH Dept of Risk Management WC	$16.39
Rate for Payer: Multiplan Commercial	$8.05
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$22.35

ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [105901]

Facility

$29.80

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$23.84
Rate for Payer: Cash Price	$16.39
Rate for Payer: Cash Price	$5.91
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.59
Rate for Payer: Health Smart Auto/Commercial	$6.44
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$17.88
Rate for Payer: LLUH Dept of Risk Management WC	$16.39
Rate for Payer: LLUH Dept of Risk Management WC	$5.91
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$8.05
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$22.35

ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]

Facility

$11.10

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$8.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$6.66
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$6.66
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$6.11
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$8.32

ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [105902]

Facility

$18.00

Service Code	HCPCS J1650
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$6.66
Rate for Payer: LLUH Dept of Risk Management WC	$6.11
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$8.32
Rate for Payer: Multiplan Commercial	$13.50

ENTACAPONE 200 MG TABLET [26547]

Facility

$4.94

Service Code	NDC 60687-188-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$3.95
Rate for Payer: Cash Price	$2.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.95
Rate for Payer: Health Smart Auto/Commercial	$2.96
Rate for Payer: LLUH Dept of Risk Management WC	$2.72
Rate for Payer: Multiplan Commercial	$3.71

ENTACAPONE 200 MG TABLET [26547]

Facility

$0.58

Service Code	NDC 33342-260-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

ENTACAPONE 200 MG TABLET [26547]

Facility

$4.94

Service Code	NDC 60687-188-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$3.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.96
Rate for Payer: Aetna of CA Government/Medicare	$2.96
Rate for Payer: Cash Price	$2.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.95
Rate for Payer: Health Smart Auto/Commercial	$2.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.96
Rate for Payer: LLUH Dept of Risk Management WC	$2.72
Rate for Payer: Multiplan Commercial	$3.71

ENTACAPONE 200 MG TABLET [26547]

Facility

$0.58

Service Code	NDC 33342-260-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

ENTACAPONE 200 MG TABLET [26547]

Facility

$4.94

Service Code	NDC 60687-188-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$3.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.96
Rate for Payer: Aetna of CA Government/Medicare	$2.96
Rate for Payer: Cash Price	$2.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.95
Rate for Payer: Health Smart Auto/Commercial	$2.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.96
Rate for Payer: LLUH Dept of Risk Management WC	$2.72
Rate for Payer: Multiplan Commercial	$3.71

Know your out-of-pocket cost for care.

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