Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

EPINEPHRINE 1 MG/10 ML SYRINGE - CODE [4080580]

Facility

$1.18

Service Code	CPT J0171
Hospital Charge Code	1720163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

EPINEPHRINE 1 MG/10 ML SYRINGE - CODE [4080580]

Facility

$1.18

Service Code	CPT J0171
Hospital Charge Code	1720163
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION WRAP [408187508]

Facility

$17.95

Service Code	CPT J0171
Hospital Charge Code	1720457
Hospital Revenue Code	636
Min. Negotiated Rate	$9.87
Max. Negotiated Rate	$13.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.77
Rate for Payer: Aetna of CA Government/Medicare	$10.77
Rate for Payer: Cash Price	$8.08
Rate for Payer: Health Smart Auto/Commercial	$10.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.77
Rate for Payer: LLUH Dept of Risk Management WC	$9.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.46

EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION WRAP [408187508]

Facility

$975.30

Service Code	CPT J0171
Hospital Charge Code	NDC259881
Hospital Revenue Code	636
Min. Negotiated Rate	$536.42
Max. Negotiated Rate	$780.24
Rate for Payer: Cash Price	$438.89
Rate for Payer: Cash Price	$4.05
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of CA HMO/PPO	$7.19
Rate for Payer: Cigna of CA HMO/PPO	$780.24
Rate for Payer: Cigna of CA HMO/PPO	$10.56
Rate for Payer: Health Smart Auto/Commercial	$5.39
Rate for Payer: Health Smart Auto/Commercial	$585.18
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$4.94
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: LLUH Dept of Risk Management WC	$536.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$731.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.74

EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION WRAP [408187508]

Facility

$17.95

Service Code	CPT J0171
Hospital Charge Code	1720457
Hospital Revenue Code	636
Min. Negotiated Rate	$9.87
Max. Negotiated Rate	$14.36
Rate for Payer: Cash Price	$8.08
Rate for Payer: Cigna of CA HMO/PPO	$14.36
Rate for Payer: Health Smart Auto/Commercial	$10.77
Rate for Payer: LLUH Dept of Risk Management WC	$9.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.46

EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION WRAP [408187508]

Facility

$8.99

Service Code	CPT J0171
Hospital Charge Code	NDC259881
Hospital Revenue Code	636
Min. Negotiated Rate	$4.94
Max. Negotiated Rate	$6.74
Rate for Payer: Health Smart Auto/Commercial	$585.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$585.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$585.18
Rate for Payer: Aetna of CA Government/Medicare	$7.92
Rate for Payer: Aetna of CA Government/Medicare	$5.39
Rate for Payer: Cash Price	$438.89
Rate for Payer: Cash Price	$4.05
Rate for Payer: Cash Price	$5.94
Rate for Payer: Health Smart Auto/Commercial	$5.39
Rate for Payer: Health Smart Auto/Commercial	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$585.18
Rate for Payer: LLUH Dept of Risk Management WC	$536.42
Rate for Payer: LLUH Dept of Risk Management WC	$4.94
Rate for Payer: LLUH Dept of Risk Management WC	$7.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$731.48

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$10.80

Service Code	CPT J0171
Hospital Charge Code	NDG2850B
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.48
Rate for Payer: Aetna of CA Government/Medicare	$6.48
Rate for Payer: Cash Price	$4.86
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.10

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$10.80

Service Code	CPT J0171
Hospital Charge Code	NDG2850B
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Cash Price	$4.86
Rate for Payer: Cigna of CA HMO/PPO	$8.64
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.10

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$9.00

Service Code	CPT J0171
Hospital Charge Code	1759134
Hospital Revenue Code	636
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Cash Price	$4.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$6.75

EPINEPHRINE 1 MG/ML INJECTION SOLUTION [2850]

Facility

$9.00

Service Code	CPT J0171
Hospital Charge Code	1759134
Hospital Revenue Code	636
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$6.75
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	$4.05
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 Beech St/Commercial/PHCS	$6.75

EPINEPHRINE 1 MG/ML NASAL SOLUTION [19604]

Facility

$10.02

Service Code	NDC 42023-103-01
Hospital Charge Code	1743059
Hospital Revenue Code	259
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$7.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.01
Rate for Payer: Aetna of CA Government/Medicare	$6.01
Rate for Payer: Cash Price	$4.51
Rate for Payer: Health Smart Auto/Commercial	$6.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.01
Rate for Payer: LLUH Dept of Risk Management WC	$5.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.52

EPINEPHRINE 1 MG/ML NASAL SOLUTION [19604]

Facility

$10.02

Service Code	NDC 42023-103-01
Hospital Charge Code	1743059
Hospital Revenue Code	259
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$8.02
Rate for Payer: Cash Price	$4.51
Rate for Payer: Cigna of CA HMO/PPO	$8.02
Rate for Payer: Health Smart Auto/Commercial	$6.01
Rate for Payer: LLUH Dept of Risk Management WC	$5.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.52

EPINEPHRINE 2.5 MG/50 ML NS SYRINGE [4080666]

Facility

$15.00

Service Code	CPT J0171
Hospital Charge Code	NDC4080666
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 2.5 MG/50 ML NS SYRINGE [4080666]

Facility

$15.00

Service Code	CPT J0171
Hospital Charge Code	NDC4080666
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 HCL 100 MCG/10 ML (10 MCG/ML) IN D5W INTRAVENOUS SYRINGE [220347]

Facility

$0.79

Service Code	CPT J0171
Hospital Charge Code	NDG220347A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

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

Facility

$0.79

Service Code	CPT J0171
Hospital Charge Code	NDG220347A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

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

Facility

$0.02

Service Code	CPT J0171
Hospital Charge Code	1712561
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.02

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

Facility

$0.02

Service Code	CPT J0171
Hospital Charge Code	1712561
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: 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 Beech St/Commercial/PHCS	$0.02

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

Facility

$13.20

Service Code	CPT J0171
Hospital Charge Code	NDC259881
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$9.90

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

Facility

$13.20

Service Code	CPT J0171
Hospital Charge Code	NDC259881
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$9.90
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	$5.94
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 Beech St/Commercial/PHCS	$9.90

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

Facility

$13.20

Service Code	CPT J0171
Hospital Charge Code	NDC259881
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$10.56
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$9.90

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

Facility

$13.20

Service Code	CPT J0171
Hospital Charge Code	NDC259881
Hospital Revenue Code	636
Min. Negotiated Rate	$7.26
Max. Negotiated Rate	$9.90
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	$5.94
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 Beech St/Commercial/PHCS	$9.90

EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION [88009]

Facility

$2.32

Service Code	CPT J9178
Hospital Charge Code	NDG88009
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cigna of CA HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.39
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.74

EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION [88009]

Facility

$2.32

Service Code	CPT J9178
Hospital Charge Code	NDG88009
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.74
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	$1.04
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	$1.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.74

Know your out-of-pocket cost for care.

All Charges