Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION [9938]

Facility

$320.69

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$176.38
Max. Negotiated Rate	$256.55
Rate for Payer: Cash Price	$176.38
Rate for Payer: Cash Price	$109.43
Rate for Payer: Cash Price	$176.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$256.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$256.55
Rate for Payer: Health Smart Auto/Commercial	$192.42
Rate for Payer: Health Smart Auto/Commercial	$192.41
Rate for Payer: Health Smart Auto/Commercial	$119.38
Rate for Payer: LLUH Dept of Risk Management WC	$109.43
Rate for Payer: LLUH Dept of Risk Management WC	$176.38
Rate for Payer: LLUH Dept of Risk Management WC	$176.38
Rate for Payer: Multiplan Commercial	$240.52
Rate for Payer: Multiplan Commercial	$149.22
Rate for Payer: Multiplan Commercial	$240.53

EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION [9938]

Facility

$320.69

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$176.38
Max. Negotiated Rate	$256.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$192.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$192.42
Rate for Payer: Aetna of CA Government/Medicare	$192.41
Rate for Payer: Aetna of CA Government/Medicare	$119.38
Rate for Payer: Aetna of CA Government/Medicare	$192.42
Rate for Payer: Cash Price	$176.39
Rate for Payer: Cash Price	$109.43
Rate for Payer: Cash Price	$176.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$256.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$256.56
Rate for Payer: Health Smart Auto/Commercial	$119.38
Rate for Payer: Health Smart Auto/Commercial	$192.41
Rate for Payer: Health Smart Auto/Commercial	$192.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$192.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$192.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.38
Rate for Payer: LLUH Dept of Risk Management WC	$109.43
Rate for Payer: LLUH Dept of Risk Management WC	$176.38
Rate for Payer: LLUH Dept of Risk Management WC	$176.38
Rate for Payer: Multiplan Commercial	$149.22
Rate for Payer: Multiplan Commercial	$240.52
Rate for Payer: Multiplan Commercial	$240.53

EPOETIN ALFA 20,000 UNIT/2 ML INJECTION SOLUTION [117367]

Facility

$198.96

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$109.43
Max. Negotiated Rate	$159.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.38
Rate for Payer: Aetna of CA Government/Medicare	$119.38
Rate for Payer: Cash Price	$109.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.17
Rate for Payer: Health Smart Auto/Commercial	$119.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.38
Rate for Payer: LLUH Dept of Risk Management WC	$109.43
Rate for Payer: Multiplan Commercial	$149.22

EPOETIN ALFA 20,000 UNIT/2 ML INJECTION SOLUTION [117367]

Facility

$198.96

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$109.43
Max. Negotiated Rate	$159.17
Rate for Payer: Cash Price	$109.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.17
Rate for Payer: Health Smart Auto/Commercial	$119.38
Rate for Payer: LLUH Dept of Risk Management WC	$109.43
Rate for Payer: Multiplan Commercial	$149.22

EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]

Facility

$641.40

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$352.77
Max. Negotiated Rate	$513.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$384.84
Rate for Payer: Aetna of CA Government/Medicare	$384.84
Rate for Payer: Cash Price	$352.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$513.12
Rate for Payer: Health Smart Auto/Commercial	$384.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$384.84
Rate for Payer: LLUH Dept of Risk Management WC	$352.77
Rate for Payer: Multiplan Commercial	$481.05

EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]

Facility

$641.40

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$352.77
Max. Negotiated Rate	$513.12
Rate for Payer: Cash Price	$352.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$513.12
Rate for Payer: Health Smart Auto/Commercial	$384.84
Rate for Payer: LLUH Dept of Risk Management WC	$352.77
Rate for Payer: Multiplan Commercial	$481.05

EPOETIN ALFA 2,000 UNIT/ML INJECTION SOLUTION [9939]

Facility

$39.79

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$21.88
Max. Negotiated Rate	$31.83
Rate for Payer: Cash Price	$21.89
Rate for Payer: Cash Price	$35.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.83
Rate for Payer: Health Smart Auto/Commercial	$23.87
Rate for Payer: Health Smart Auto/Commercial	$38.49
Rate for Payer: LLUH Dept of Risk Management WC	$21.88
Rate for Payer: LLUH Dept of Risk Management WC	$35.28
Rate for Payer: Multiplan Commercial	$29.84
Rate for Payer: Multiplan Commercial	$48.11

EPOETIN ALFA 2,000 UNIT/ML INJECTION SOLUTION [9939]

Facility

$64.15

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$51.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.87
Rate for Payer: Aetna of CA Government/Medicare	$23.87
Rate for Payer: Aetna of CA Government/Medicare	$38.49
Rate for Payer: Cash Price	$21.89
Rate for Payer: Cash Price	$35.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.83
Rate for Payer: Health Smart Auto/Commercial	$38.49
Rate for Payer: Health Smart Auto/Commercial	$23.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.49
Rate for Payer: LLUH Dept of Risk Management WC	$21.88
Rate for Payer: LLUH Dept of Risk Management WC	$35.28
Rate for Payer: Multiplan Commercial	$48.11
Rate for Payer: Multiplan Commercial	$29.84

EPOETIN ALFA 3,000 UNIT/ML INJECTION SOLUTION [9940]

Facility

$59.69

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$32.83
Max. Negotiated Rate	$47.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.73
Rate for Payer: Aetna of CA Government/Medicare	$57.73
Rate for Payer: Aetna of CA Government/Medicare	$35.81
Rate for Payer: Cash Price	$52.92
Rate for Payer: Cash Price	$32.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.98
Rate for Payer: Health Smart Auto/Commercial	$35.81
Rate for Payer: Health Smart Auto/Commercial	$57.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.73
Rate for Payer: LLUH Dept of Risk Management WC	$32.83
Rate for Payer: LLUH Dept of Risk Management WC	$52.92
Rate for Payer: Multiplan Commercial	$72.17
Rate for Payer: Multiplan Commercial	$44.77

EPOETIN ALFA 3,000 UNIT/ML INJECTION SOLUTION [9940]

Facility

$96.22

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$76.98
Rate for Payer: Cash Price	$52.92
Rate for Payer: Cash Price	$32.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.98
Rate for Payer: Health Smart Auto/Commercial	$57.73
Rate for Payer: Health Smart Auto/Commercial	$35.81
Rate for Payer: LLUH Dept of Risk Management WC	$32.83
Rate for Payer: LLUH Dept of Risk Management WC	$52.92
Rate for Payer: Multiplan Commercial	$44.77
Rate for Payer: Multiplan Commercial	$72.17

EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION [9941]

Facility

$128.28

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$102.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$76.97
Rate for Payer: Aetna of CA Government/Medicare	$76.97
Rate for Payer: Cash Price	$70.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$102.62
Rate for Payer: Health Smart Auto/Commercial	$76.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$76.97
Rate for Payer: LLUH Dept of Risk Management WC	$70.55
Rate for Payer: Multiplan Commercial	$96.21

EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION [9941]

Facility

$128.28

Service Code	HCPCS J0885
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$102.62
Rate for Payer: Cash Price	$70.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$102.62
Rate for Payer: Health Smart Auto/Commercial	$76.97
Rate for Payer: LLUH Dept of Risk Management WC	$70.55
Rate for Payer: Multiplan Commercial	$96.21

EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [221922]

Facility

$132.36

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$105.89
Rate for Payer: Cash Price	$72.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.89
Rate for Payer: Health Smart Auto/Commercial	$79.42
Rate for Payer: LLUH Dept of Risk Management WC	$72.80
Rate for Payer: Multiplan Commercial	$99.27

EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [221922]

Facility

$132.36

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$105.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$79.42
Rate for Payer: Aetna of CA Government/Medicare	$79.42
Rate for Payer: Cash Price	$72.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.89
Rate for Payer: Health Smart Auto/Commercial	$79.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$79.42
Rate for Payer: LLUH Dept of Risk Management WC	$72.80
Rate for Payer: Multiplan Commercial	$99.27

EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [229807]

Facility

$264.72

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$211.78
Rate for Payer: Cash Price	$145.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.78
Rate for Payer: Health Smart Auto/Commercial	$158.83
Rate for Payer: LLUH Dept of Risk Management WC	$145.60
Rate for Payer: Multiplan Commercial	$198.54

EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [229807]

Facility

$264.72

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$211.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$158.83
Rate for Payer: Aetna of CA Government/Medicare	$158.83
Rate for Payer: Cash Price	$145.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.78
Rate for Payer: Health Smart Auto/Commercial	$158.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$158.83
Rate for Payer: LLUH Dept of Risk Management WC	$145.60
Rate for Payer: Multiplan Commercial	$198.54

EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION [221919]

Facility

$26.47

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$14.56
Max. Negotiated Rate	$21.18
Rate for Payer: Cash Price	$14.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.18
Rate for Payer: Health Smart Auto/Commercial	$15.88
Rate for Payer: LLUH Dept of Risk Management WC	$14.56
Rate for Payer: Multiplan Commercial	$19.85

EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION [221919]

Facility

$26.47

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$14.56
Max. Negotiated Rate	$21.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.88
Rate for Payer: Aetna of CA Government/Medicare	$15.88
Rate for Payer: Cash Price	$14.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.18
Rate for Payer: Health Smart Auto/Commercial	$15.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.88
Rate for Payer: LLUH Dept of Risk Management WC	$14.56
Rate for Payer: Multiplan Commercial	$19.85

EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION [221920]

Facility

$39.71

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$31.77
Rate for Payer: Cash Price	$21.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.77
Rate for Payer: Health Smart Auto/Commercial	$23.83
Rate for Payer: LLUH Dept of Risk Management WC	$21.84
Rate for Payer: Multiplan Commercial	$29.78

EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION [221920]

Facility

$39.71

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$31.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.83
Rate for Payer: Aetna of CA Government/Medicare	$23.83
Rate for Payer: Cash Price	$21.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.77
Rate for Payer: Health Smart Auto/Commercial	$23.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.83
Rate for Payer: LLUH Dept of Risk Management WC	$21.84
Rate for Payer: Multiplan Commercial	$29.78

EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [221923]

Facility

$529.44

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$291.19
Max. Negotiated Rate	$423.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$317.66
Rate for Payer: Aetna of CA Government/Medicare	$317.66
Rate for Payer: Cash Price	$291.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$423.55
Rate for Payer: Health Smart Auto/Commercial	$317.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$317.66
Rate for Payer: LLUH Dept of Risk Management WC	$291.19
Rate for Payer: Multiplan Commercial	$397.08

EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [221923]

Facility

$529.44

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$291.19
Max. Negotiated Rate	$423.55
Rate for Payer: Cash Price	$291.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$423.55
Rate for Payer: Health Smart Auto/Commercial	$317.66
Rate for Payer: LLUH Dept of Risk Management WC	$291.19
Rate for Payer: Multiplan Commercial	$397.08

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]

Facility

$52.94

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$42.35
Rate for Payer: Cash Price	$29.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.35
Rate for Payer: Health Smart Auto/Commercial	$31.76
Rate for Payer: LLUH Dept of Risk Management WC	$29.12
Rate for Payer: Multiplan Commercial	$39.70

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]

Facility

$52.94

Service Code	HCPCS Q5106
Hospital Charge Code	901700041
Hospital Revenue Code	636
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$42.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.76
Rate for Payer: Aetna of CA Government/Medicare	$31.76
Rate for Payer: Cash Price	$29.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.35
Rate for Payer: Health Smart Auto/Commercial	$31.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.76
Rate for Payer: LLUH Dept of Risk Management WC	$29.12
Rate for Payer: Multiplan Commercial	$39.70

EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]

Facility

$53.40

Service Code	HCPCS J1325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.37
Max. Negotiated Rate	$42.72
Rate for Payer: Cash Price	$29.37
Rate for Payer: Cash Price	$36.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.72
Rate for Payer: Health Smart Auto/Commercial	$32.04
Rate for Payer: Health Smart Auto/Commercial	$39.79
Rate for Payer: LLUH Dept of Risk Management WC	$29.37
Rate for Payer: LLUH Dept of Risk Management WC	$36.47
Rate for Payer: Multiplan Commercial	$40.05
Rate for Payer: Multiplan Commercial	$49.73

Know your out-of-pocket cost for care.

All Charges