Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$9.00

Service Code	HCPCS J0168
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$10.80

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cash Price	$4.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$8.10
Rate for Payer: Multiplan Commercial	$6.00

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$10.80

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.80
Rate for Payer: Aetna of CA Government/Medicare	$6.48
Rate for Payer: Aetna of CA Government/Medicare	$4.80
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cash Price	$4.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$8.10
Rate for Payer: Multiplan Commercial	$6.00

EPINEPHRINE 2.5 MG/50 ML NS SYRINGE [4080666]

Facility

$15.00

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$8.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

EPINEPHRINE 2.5 MG/50 ML NS SYRINGE [4080666]

Facility

$15.00

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$8.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE [220347]

Facility

$0.80

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.60

EPINEPHRINE HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE [220347]

Facility

$0.80

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
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	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
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 Commercial	$0.60

EPINEPHRINE HCL 50 MCG/5 ML(10 MCG/ML)IN 0.9 % SOD.CHLORIDE IV SYRINGE [211782]

Facility

$0.02

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

EPINEPHRINE HCL 50 MCG/5 ML(10 MCG/ML)IN 0.9 % SOD.CHLORIDE IV SYRINGE [211782]

Facility

$0.02

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [118405]

Facility

$13.20

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [118405]

Facility

$13.20

Service Code	HCPCS J0166
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [118405]

Facility

$13.20

Service Code	HCPCS J0166
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [118405]

Facility

$13.20

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE IV INFUSION IN NS (LL) [40820174]

Facility

$9.00

Service Code	NDC 9940-8201-72
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

EPINEPHRINE IV INFUSION IN NS (LL) [40820174]

Facility

$9.00

Service Code	NDC 9940-8201-72
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$6.75

EPINEPHRINE (PF) 1 MG/ML (1:1,000) (1 ML) INJECTION FOR DRIPS [4080899]

Facility

$13.20

Service Code	HCPCS J0166
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE (PF) 1 MG/ML (1:1,000) (1 ML) INJECTION FOR DRIPS [4080899]

Facility

$13.20

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE (PF) 1 MG/ML (1:1,000) (1 ML) INJECTION FOR DRIPS [4080899]

Facility

$13.20

Service Code	HCPCS J0166
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPINEPHRINE (PF) 1 MG/ML (1:1,000) (1 ML) INJECTION FOR DRIPS [4080899]

Facility

$13.20

Service Code	HCPCS J0165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Commercial	$9.90

EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [88008]

Facility

$2.31

Service Code	HCPCS J9178
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.39
Rate for Payer: Aetna of CA Government/Medicare	$1.39
Rate for Payer: Cash Price	$1.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.85
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.27
Rate for Payer: Multiplan Commercial	$1.73

EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [88008]

Facility

$2.31

Service Code	HCPCS J9178
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$1.85
Rate for Payer: Cash Price	$1.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.85
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.27
Rate for Payer: Multiplan Commercial	$1.73

EPLERENONE 25 MG TABLET [36983]

Facility

$1.68

Service Code	NDC 69367-307-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

EPLERENONE 25 MG TABLET [36983]

Facility

$1.68

Service Code	NDC 16729-293-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

EPLERENONE 25 MG TABLET [36983]

Facility

$1.68

Service Code	NDC 16729-293-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

EPLERENONE 25 MG TABLET [36983]

Facility

$1.68

Service Code	NDC 69367-307-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

Know your out-of-pocket cost for care.

All Charges