Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$34.05

Service Code	NDC 0781-3269-71
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$18.73
Max. Negotiated Rate	$25.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.43
Rate for Payer: Aetna of CA Government/Medicare	$20.43
Rate for Payer: Cash Price	$15.32
Rate for Payer: Health Smart Auto/Commercial	$20.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.43
Rate for Payer: LLUH Dept of Risk Management WC	$18.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.54

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$13.37

Service Code	NDC 70756-611-82
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.70
Rate for Payer: Cash Price	$6.02
Rate for Payer: Cigna of CA HMO/PPO	$10.70
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.03

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$13.37

Service Code	NDC 70756-611-82
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.02
Rate for Payer: Aetna of CA Government/Medicare	$8.02
Rate for Payer: Cash Price	$6.02
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.03

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$56.75

Service Code	NDC 70121-1637-7
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$31.21
Max. Negotiated Rate	$45.40
Rate for Payer: Cash Price	$25.54
Rate for Payer: Cigna of CA HMO/PPO	$45.40
Rate for Payer: Health Smart Auto/Commercial	$34.05
Rate for Payer: LLUH Dept of Risk Management WC	$31.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.56

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$34.05

Service Code	NDC 0781-3269-95
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$18.73
Max. Negotiated Rate	$27.24
Rate for Payer: Cash Price	$15.32
Rate for Payer: Cigna of CA HMO/PPO	$27.24
Rate for Payer: Health Smart Auto/Commercial	$20.43
Rate for Payer: LLUH Dept of Risk Management WC	$18.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.54

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$34.85

Service Code	NDC 70121-1637-1
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$19.17
Max. Negotiated Rate	$27.88
Rate for Payer: Cash Price	$15.68
Rate for Payer: Cigna of CA HMO/PPO	$27.88
Rate for Payer: Health Smart Auto/Commercial	$20.91
Rate for Payer: LLUH Dept of Risk Management WC	$19.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.14

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$13.37

Service Code	NDC 70756-611-25
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$10.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.02
Rate for Payer: Aetna of CA Government/Medicare	$8.02
Rate for Payer: Cash Price	$6.02
Rate for Payer: Health Smart Auto/Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.02
Rate for Payer: LLUH Dept of Risk Management WC	$7.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.03

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$9.35

Service Code	NDC 70700-249-25
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$5.14
Max. Negotiated Rate	$7.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.61
Rate for Payer: Aetna of CA Government/Medicare	$5.61
Rate for Payer: Cash Price	$4.21
Rate for Payer: Health Smart Auto/Commercial	$5.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.61
Rate for Payer: LLUH Dept of Risk Management WC	$5.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.01

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$9.35

Service Code	NDC 70700-249-25
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$5.14
Max. Negotiated Rate	$7.48
Rate for Payer: Cash Price	$4.21
Rate for Payer: Cigna of CA HMO/PPO	$7.48
Rate for Payer: Health Smart Auto/Commercial	$5.61
Rate for Payer: LLUH Dept of Risk Management WC	$5.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.01

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$34.85

Service Code	NDC 70121-1637-1
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$19.17
Max. Negotiated Rate	$26.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.91
Rate for Payer: Aetna of CA Government/Medicare	$20.91
Rate for Payer: Cash Price	$15.68
Rate for Payer: Health Smart Auto/Commercial	$20.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.91
Rate for Payer: LLUH Dept of Risk Management WC	$19.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.14

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$14.96

Service Code	NDC 70700-249-22
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$11.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.98
Rate for Payer: Aetna of CA Government/Medicare	$8.98
Rate for Payer: Cash Price	$6.73
Rate for Payer: Health Smart Auto/Commercial	$8.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.98
Rate for Payer: LLUH Dept of Risk Management WC	$8.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.22

EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]

Facility

$34.05

Service Code	NDC 0781-3269-95
Hospital Charge Code	1720234
Hospital Revenue Code	250
Min. Negotiated Rate	$18.73
Max. Negotiated Rate	$25.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.43
Rate for Payer: Aetna of CA Government/Medicare	$20.43
Rate for Payer: Cash Price	$15.32
Rate for Payer: Health Smart Auto/Commercial	$20.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.43
Rate for Payer: LLUH Dept of Risk Management WC	$18.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.54

EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION [227763]

Facility

$3.48

Service Code	NDC 42023-243-01
Hospital Charge Code	NDG227763
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.09
Rate for Payer: Aetna of CA Government/Medicare	$2.09
Rate for Payer: Cash Price	$1.57
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.61

EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION [227763]

Facility

$3.48

Service Code	NDC 14789-250-07
Hospital Charge Code	NDG227763
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Cash Price	$1.57
Rate for Payer: Cigna of CA HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.61

EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION [227763]

Facility

$3.36

Service Code	NDC 14789-250-10
Hospital Charge Code	NDG227763
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.69
Rate for Payer: Cash Price	$1.51
Rate for Payer: Cigna of CA HMO/PPO	$2.69
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION [227763]

Facility

$3.48

Service Code	NDC 42023-243-01
Hospital Charge Code	NDG227763
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Cash Price	$1.57
Rate for Payer: Cigna of CA HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.61

EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION [227763]

Facility

$3.48

Service Code	NDC 14789-250-07
Hospital Charge Code	NDG227763
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.09
Rate for Payer: Aetna of CA Government/Medicare	$2.09
Rate for Payer: Cash Price	$1.57
Rate for Payer: Health Smart Auto/Commercial	$2.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.61

EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION [227763]

Facility

$3.36

Service Code	NDC 14789-250-10
Hospital Charge Code	NDG227763
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.02
Rate for Payer: Aetna of CA Government/Medicare	$2.02
Rate for Payer: Cash Price	$1.51
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.52

EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE (10 ML) [2848]

Facility

$1.50

Service Code	CPT J0171
Hospital Charge Code	1720163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE (10 ML) [2848]

Facility

$1.50

Service Code	CPT J0171
Hospital Charge Code	1720163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.12

EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR [100491]

Facility

$180.00

Service Code	CPT J0171
Hospital Charge Code	1720899
Hospital Revenue Code	636
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$108.00
Rate for Payer: Aetna of CA Government/Medicare	$108.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Smart Auto/Commercial	$108.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$108.00
Rate for Payer: LLUH Dept of Risk Management WC	$99.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$135.00

EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR [100491]

Facility

$180.00

Service Code	CPT J0171
Hospital Charge Code	1720899
Hospital Revenue Code	636
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$144.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna of CA HMO/PPO	$144.00
Rate for Payer: Health Smart Auto/Commercial	$108.00
Rate for Payer: LLUH Dept of Risk Management WC	$99.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$135.00

EPINEPHRINE 1.25 MG/50 ML NS SYRINGE [4080665]

Facility

$15.00

Service Code	CPT J0171
Hospital Charge Code	NDC4080665
Hospital Revenue Code	636
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$11.25

EPINEPHRINE 1.25 MG/50 ML NS SYRINGE [4080665]

Facility

$15.00

Service Code	CPT J0171
Hospital Charge Code	NDC4080665
Hospital Revenue Code	636
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
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	$6.75
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 Beech St/Commercial/PHCS	$11.25

EPINEPHRINE 1 MG/10 ML (100 MCG/ML) IN SODIUM CHLOR,ISO-OSM IV SYRINGE [224815]

Facility

$0.55

Service Code	NDC 69374-925-10
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

Know your out-of-pocket cost for care.

All Charges