Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]

Facility

$22.43

Service Code	HCPCS J1325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.34
Max. Negotiated Rate	$17.94
Rate for Payer: Cash Price	$12.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.94
Rate for Payer: Health Smart Auto/Commercial	$13.46
Rate for Payer: LLUH Dept of Risk Management WC	$12.34
Rate for Payer: Multiplan Commercial	$16.82

EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]

Facility

$22.43

Service Code	HCPCS J1325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.34
Max. Negotiated Rate	$17.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.46
Rate for Payer: Aetna of CA Government/Medicare	$13.46
Rate for Payer: Cash Price	$12.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.94
Rate for Payer: Health Smart Auto/Commercial	$13.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.46
Rate for Payer: LLUH Dept of Risk Management WC	$12.34
Rate for Payer: Multiplan Commercial	$16.82

EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]

Facility

$54.17

Service Code	HCPCS J1325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.79
Max. Negotiated Rate	$43.34
Rate for Payer: Cash Price	$29.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.34
Rate for Payer: Health Smart Auto/Commercial	$32.50
Rate for Payer: LLUH Dept of Risk Management WC	$29.79
Rate for Payer: Multiplan Commercial	$40.63

EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]

Facility

$54.17

Service Code	HCPCS J1325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.79
Max. Negotiated Rate	$43.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.50
Rate for Payer: Aetna of CA Government/Medicare	$32.50
Rate for Payer: Cash Price	$29.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.34
Rate for Payer: Health Smart Auto/Commercial	$32.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.50
Rate for Payer: LLUH Dept of Risk Management WC	$29.79
Rate for Payer: Multiplan Commercial	$40.63

EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]

Facility

$1.80

Service Code	HCPCS J1327
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.35

EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]

Facility

$1.80

Service Code	HCPCS J1327
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.35

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$6.00

Service Code	HCPCS J1327
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$5.40

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$4.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.77
Rate for Payer: Aetna of CA Government/Medicare	$6.77
Rate for Payer: Aetna of CA Government/Medicare	$3.24
Rate for Payer: Cash Price	$6.20
Rate for Payer: Cash Price	$2.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.02
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: Health Smart Auto/Commercial	$6.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Commercial	$4.05
Rate for Payer: Multiplan Commercial	$8.46

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$11.28

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$9.02
Rate for Payer: Cash Price	$6.20
Rate for Payer: Cash Price	$2.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.02
Rate for Payer: Health Smart Auto/Commercial	$6.77
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Commercial	$8.46
Rate for Payer: Multiplan Commercial	$4.05

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$6.00

Service Code	HCPCS J1327
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]

Facility

$80.50

Service Code	HCPCS J0122
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.27
Max. Negotiated Rate	$64.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.30
Rate for Payer: Aetna of CA Government/Medicare	$48.30
Rate for Payer: Cash Price	$44.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.40
Rate for Payer: Health Smart Auto/Commercial	$48.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.30
Rate for Payer: LLUH Dept of Risk Management WC	$44.27
Rate for Payer: Multiplan Commercial	$60.38

ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]

Facility

$80.50

Service Code	HCPCS J0122
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.27
Max. Negotiated Rate	$64.40
Rate for Payer: Cash Price	$44.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.40
Rate for Payer: Health Smart Auto/Commercial	$48.30
Rate for Payer: LLUH Dept of Risk Management WC	$44.27
Rate for Payer: Multiplan Commercial	$60.38

ERDAFITINIB 3 MG TABLET [224623]

Facility

$455.28

Service Code	NDC 59676-030-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$250.40
Max. Negotiated Rate	$364.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$273.17
Rate for Payer: Aetna of CA Government/Medicare	$273.17
Rate for Payer: Cash Price	$250.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$364.22
Rate for Payer: Health Smart Auto/Commercial	$273.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$273.17
Rate for Payer: LLUH Dept of Risk Management WC	$250.40
Rate for Payer: Multiplan Commercial	$341.46

ERDAFITINIB 3 MG TABLET [224623]

Facility

$455.28

Service Code	NDC 59676-030-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$250.40
Max. Negotiated Rate	$364.22
Rate for Payer: Cash Price	$250.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$364.22
Rate for Payer: Health Smart Auto/Commercial	$273.17
Rate for Payer: LLUH Dept of Risk Management WC	$250.40
Rate for Payer: Multiplan Commercial	$341.46

ERDAFITINIB 4 MG TABLET [224624]

Facility

$607.04

Service Code	NDC 59676-040-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$333.87
Max. Negotiated Rate	$485.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$364.22
Rate for Payer: Aetna of CA Government/Medicare	$364.22
Rate for Payer: Cash Price	$333.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$485.63
Rate for Payer: Health Smart Auto/Commercial	$364.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$364.22
Rate for Payer: LLUH Dept of Risk Management WC	$333.87
Rate for Payer: Multiplan Commercial	$455.28

ERDAFITINIB 4 MG TABLET [224624]

Facility

$607.04

Service Code	NDC 59676-040-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$333.87
Max. Negotiated Rate	$485.63
Rate for Payer: Cash Price	$333.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$485.63
Rate for Payer: Health Smart Auto/Commercial	$364.22
Rate for Payer: LLUH Dept of Risk Management WC	$333.87
Rate for Payer: Multiplan Commercial	$455.28

ERDAFITINIB 5 MG TABLET [224625]

Facility

$758.80

Service Code	NDC 59676-050-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$417.34
Max. Negotiated Rate	$607.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$455.28
Rate for Payer: Aetna of CA Government/Medicare	$455.28
Rate for Payer: Cash Price	$417.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$607.04
Rate for Payer: Health Smart Auto/Commercial	$455.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$455.28
Rate for Payer: LLUH Dept of Risk Management WC	$417.34
Rate for Payer: Multiplan Commercial	$569.10

ERDAFITINIB 5 MG TABLET [224625]

Facility

$758.80

Service Code	NDC 59676-050-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$417.34
Max. Negotiated Rate	$607.04
Rate for Payer: Cash Price	$417.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$607.04
Rate for Payer: Health Smart Auto/Commercial	$455.28
Rate for Payer: LLUH Dept of Risk Management WC	$417.34
Rate for Payer: Multiplan Commercial	$569.10

ERENUMAB-AOOE 70 MG/ML SUBCUTANEOUS AUTO-INJECTOR [221765]

Facility

$921.20

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$506.66
Max. Negotiated Rate	$736.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$552.72
Rate for Payer: Aetna of CA Government/Medicare	$552.72
Rate for Payer: Cash Price	$506.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$736.96
Rate for Payer: Health Smart Auto/Commercial	$552.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$552.72
Rate for Payer: LLUH Dept of Risk Management WC	$506.66
Rate for Payer: Multiplan Commercial	$690.90

ERENUMAB-AOOE 70 MG/ML SUBCUTANEOUS AUTO-INJECTOR [221765]

Facility

$921.20

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$506.66
Max. Negotiated Rate	$736.96
Rate for Payer: Cash Price	$506.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$736.96
Rate for Payer: Health Smart Auto/Commercial	$552.72
Rate for Payer: LLUH Dept of Risk Management WC	$506.66
Rate for Payer: Multiplan Commercial	$690.90

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$0.27

Service Code	NDC 69452-151-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$1.68

Service Code	NDC 50268-297-11
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

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$1.68

Service Code	NDC 50268-297-15
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

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$0.14

Service Code	NDC 42806-547-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

Know your out-of-pocket cost for care.

All Charges